The Current Health care system directs most of its resources in direct medical services and treatment. Prevention has limited scope. Not all diseases are preventable and some of them may still occur even with all preventive measures and care taken. Hence it is important to focus on the glaring issues at hand and work to resolve them. It would be unfair to direct resources on prevention when the sick and the ailing need them.

Preventive science is still evolving as a science , what with BRCA gene screening for breast cancer , something can be done about the fact that you are at high risk of developing the disease. But this screening may not work for all, may even be wasteful in many who qualify for it. Many other diseases appropriate screening methods are yet to be established.

Another component of Health care preventive services is the health behaviours. A lot of misery can be saved by changing health behaviours and improving attitudes for healthier lifestyles. Programmes designed for these are in practise but they necessarily do not need redirection of health care dollars.

The current health care policy which directs more to actual diagnosis and treatment rather than preventive services is probably fine.

The Worst Approach

     I definitely do not think it's wise to only be spending 5% on prevention. Too many people rush themselves to the hospital over symptoms such as sneezing, runny noses, and coughs and avoid going to the doctor for more serious conditions because seeing a doctor takes too long. If people were educated on how to prevent getting minor sicknesses in the first place, they won't waste the doctor's time and the doctor can focus on more important patients. Furthermore, educating people on how to stay healthy can help them avoid developing serious conditions such as hypertension, diabetes, heart disease, etc.

     I found an article from 2001 discussing how much it cost the state of Minnesota for the inactivity of the people living there. Approximately 60% of the adults are overweight and another 17% are obese. Because of the inactive lifestyles these citizens are choosing to take, they are developing other serious illnesses such as colon cancer, breast cancer, stroke, osteoporosis, and the aforementioned disorders. 

The study showed that if these people would have just been more active, the state of Minnesota could have saved $495 million just in one year from health care costs necessary to treat these diseases and conditions which could have been prevented with an active lifestyle. This is a perfect example of why preventative measures are necessary. If these people were taught that just being more active could save them from developing these disorders, millions of dollars would have been saved. This money could have been used for the prevention of disease rather than on fixing a disease.

Link to article: http://www.health.state.mn.us/news/pressrel/inactivityfs.html

Royalties?!?!

I believe that preventative medicine has always been a part of the way in which our health care is delivered. The reason why I believe it accounts for such a small piece of the health expenditure pie is because preventative medicine mostly deals with the creation of these measures/practices. Once they have been discovered, they are adopted by the other fields of medicine that actually implement them. For example, lets talk about vaccine X that prevents disease Y. The vaccine itself may have been created from that 5% piece of the pie, but to produce it we need to pay pharma, to create the container in which it is delivered/stored we need to pay some lab company. We then need a medical doctor to determine if the vaccine is appropriate and a nurse to administer the vaccine. I can go on and on with this example, but I think I have made my point. If there was some way for royalties to be paid on every preventative measure/idea/product, maybe we would see a larger piece of the pie being taken up?!?!

When it comes to Policymaking

Like Ivett said, “If it isn’t broken, then why fix it?”  I think a lot of people have this mentality.  I, however, am not one of these people.  My education makes me more aware of what is out there and I feel like I am really big on prevention.  I mean the slightest symptom of a cold, I am taking my vitamin C, cold drops, soup, extra rest, etc. 

I think that society and the government should place a huge emphasis on prevention. If people were to keep up with their yearly physicals and/or listen to their gut feelings if something was wrong, then they would potential prolong their lives and increase their quality of life.  For example, today on Oprah, this woman had a 140 pound tumor in her stomach that was growing over the course of five years.  She went to see the doctor and he just told her to exercise more and lose weight.  He never did any blood work or any MRIs or any other tests.  It wasn’t until she was admitted into the hospital for “flu like symptoms” did they realize she had a huge tumor.  This whole time, this woman was had a gut feeling that something was wrong.  Yet she ignored her intuition. I guess the whole point of this story is that this woman could have prevented this whole situation had she listened to her gut and also if her primary care doctor gave care.

I think that the government should increase spending on preventative medicine which would ultimately decrease spending on direct medical services and thus saving the government more money.   This is all very idealistic and will probably not happen in the near future.  Even if policy was passed, it would take a very long time for the policies to actually be supported by the lucrative business of medicine.  

In order to reduce health disparities policy makers need to focus on policies that prioritize preventative medicine and providing need-based care. Preventative medicine has been proven to be cost effective in the long run, unfortunately insurance companies and individuals don't understand this cost/benefit analysis and current policy is outdated. Insurance companies have no reason to prioritize preventative medicine because they aren't guaranteed to cover an individual long enough to reap the benefit. The average lay person doesn't understand the value of preventative medicine, and even if they do they often brush it off or have issues of access. And today's policies are outdated and need to be updated to demand higher levels of preventative medicine as a standard of care. 

Policies that mandate need-based care are necessary in order to reduce health disparities. The health needs and healthcare access of different communities are highly varied. Unfortunately this means that addressing disparities demands community based solutions that are more difficult to implement than standard policies. 

When It Comes to Policymaking...

America is sick. We live lifestyles that make us sick. Had we paid attention to what would prevent such illnesses we wouldn’t see things like obesity rising to the extent that it has thus far. We need treatment and we need it quickly. The health care system, from my limited knowledge of it, seems to work on a fix-it mentality. So, if its not broke...don’t fix it. If it is broke, well then fix it really quickly before people die and there is major controversy.

Policy can dictate that money is invested in prevention but the question is: how fruitful is that investment? Prevention is up to individuals. It’s up to society. It’s fine and dandy to have charts and seminars and ad campaigns, but if the individual refuses to utilize the knowledge and continues to live lifestyles that are unhealthy and ultimately requires treatment, we better have someone on the other side preparing the dosages. There’s only so much policy can do to enforce certain lifestyles and when it does, there are often cries of injustice and infringement on consumer independence. Just like forest fires, only you can prevent illness. Unfortunately we’re choosing to dig ourselves into an early grave.

I’m honestly not sure what the answer is, but that discrepancy does seem very large. Ideally it would be great for it to be an equal split, but I don’t see that being realistic seeing how we have more diseases and illness then we know how to cure let alone understand how to prevent from occurring in the first place. There’s so much that science hasn’t answered yet and so many challenges that come with prevention. In light of how many people are sick, it’s hard to encourage that policy cut down on curing those people to invest in telling people not to do things that, trends have shown, they’ll probably just do anyway. This is a crude argument but it’s the essence of the issue. Unless we come up with more effective ways for prevention to work on a societal level, there are just too many dangerously ill people out there to shift gears right now. We obviously need a new method of prevention, not just more money.

The Potential of Prevention

There's only so much that we, as soon-to-be health officials, researchers, doctors, pharmacists, dentists, etc., can do on the prevention front. We are all well aware of the impact of smoking on lung cancer, but how effective have campaigns targeting tobacco control actually been? People haven't stopped smoking and they won't stop. So then the question becomes: Why should we invest millions upon millions of dollars into something like that when it may only turn away a small percentage of individuals?

Similarly, eating healthy and exercising is a known way to prevent obesity. When was the last time you've seen an obese individual? How many people actually take into account the preventive measures that are known to be helpful and effective in avoiding certain health outcomes? There are a few reasons that 95% of money is being spent on the treatment and just 5% on prevention: ignorance and apathy.

Americans, in particular, have become quite ignorant of known science and repeated studies that have been done to pinpoint factors relating directly to health epidemics. The facts aren't very hard to find and they are headlining the news day and night, but they tend to go unnoticed. Here's my point: How many people heard of Chris Brown's assault on his girlfriend Rihanna pre-Grammy's, resulting in both artists to cancel their performances? I'm sure everyone heard that within hours. On the other hand, how many people heard about the interview in which Papa John's founder, John Schnatter, openly said in a BBC interview that he wouldn't recommending eating more than two slices of pizza at a meal? This directly influences his business, but he is aware that even if he says that, not much will change and people will continue to devour slice after slice. Think back to Super Bowl Sunday. How many slices of pizza did you eat? How many glasses of soda? How many bottles of beer? Chips and salsa? The facts are out there. It's up to the public to decide what to do with them.

That being said, I feel that there's only so much money that can be put into preventive medicine before it all just feels like nothing but a wasted effort.

When It Comes to Policymaking...

There are many health issues that tend to go ignored and unaddressed in society today. They start off as small issues that could easily be prevented with the right tools and education. However, if the health issues go undetected and untreated, they usually turn into serious and costly health problems. It is unfortunate that only 5% of U.S. health spending goes toward prevention when prevention can significantly reduce future spending on direct medical services. Since the benefits of prevention are long-term, results usually aren't seen immediately. I can see how it might be difficult for policymakers to make that initial investment and allocate more money for prevention. However many of the problems with our health care system are due to the current unbalanced allocation of prevention and medical services. The current 5% is nothing compared to the profound influence preventative medicine could have on the health of Americans if the spending were increased.

In order to decrease health disparities, policymakers need to realize that quality health care in the U.S. is extremely expensive and for much of the population, this is a main barrier. Furthermore, cultural competence is important as well. Many people don't know of the various health services available or don't have the educational tools to access them. In this aspect, prevention plays a huge role in reducing barriers to receiving quality health care.

Prevention vs. Treatment

The U.S. healthcare system has been notorious for allocating funds towards treatment rather than prevention. We rather fix what has already been done rather than halting disease and injury in the first place. We are inclined to cure, medicate, and alleviate pain and illness; we tend not to place attention to health promotion. The flawed U.S. healthcare system's reliance on direct medical treatment fails to uphold the United Nation's vision of what being "healthy" is- which is not merely the absence of disease, it is not merely the cessation of sickness, but instead "healthy" encompasses the mental, physical, spiritual, and emotional well-being of a human. And in order to achieve that state, providers need to shift away from solely prescribing, medicaitng, and treating, they need to focus more on educating the public on overall healthy lifestyles that could prevent sickness and promote overall healthiness.

However, policy makers may not agree to this utopian vision of healthcare service delivery. For instance, I work at the Maternal & Child Adolescent Center at HSC which is a special clinic for HIV positive mothers and their families. I worked for a program within that research center which provided health education risk reduction services to incarcerated youth. The health courses aimed to educate these minors on HIV/STD transmission. The goal of the intervention was to prevent these high risk youth from being infected from HIV/AIDS and STD's. The program is contracted through the CDC as an "HERR"- health education risk reduction" intervention which contrasts "Counseling & Testing" interventions. Due to the fiscal crisis, all funding for HERR contracts were reduced by 9% and policy makers are now moving funds to counseling and testing programs. As a result of this, many public and private HIV/AIDS and STD prevention programs shut down. The defense was that...it's not that prevention is not helping halt the HIV/AIDS epidemic, but that these programs were not identifying HIV positive individuals as much as counseling and testing centers were. But if we allocate more funds towards testing, we can halt the epidemic by finding and treating those people...however the high risk groups for HIV/AIDS and STD's may perpetuate high risk behaviors if there are no preventative services available for them.

Some others reasons why only 5% of medical services is spent on prevention is due to the fact that it is difficult and complex to measure outcomes of preventative interventions and programs. It is tricky to evaluate if preventative programs are successful in healthy behavioral change. So policy makers may favor treatment and curative services since it consists of more hard evidence-based criteria of how people are getting treated, where patients are being seen, what type of services are needed etc. whereas most preventative models aim for long-term behavioral changes which may not be measurable or seen until later.

When It Comes to Policymaking....

Since the beginning of the United States healthcare system, the energy of physicians, nurses and other health professionals has been put into the curing/treatment of disease.  For the most part, it has revolved around the patient experiencing symptoms, the physician making a diagnosis and then continuing with a course of treatment.  Even though there is an abundant amount of time spent researching prevention of illness, this knowledge is not always put to the most effective use.

Yet, it is hard to say that our healthcare system is doing something wrong by spending only 5% of the money on prevention.  If we didn't spend as much as we do on treatment then so many lives would have been lost and our life expectancy as a country would seriously decline.  At least in the near future, it does not seem feasible for our system to begin cutting costs on treatment and placing more on prevention.  This is because preventive efforts will be lost on a population that is unwilling to change their behaviors.  I think the mentality of our country needs to become one of health rather than convenience before moving forward with cutting costs on treatment.

The focus of our policymakers needs to be on making early education of healthy lifestyles mandatory in schools.  There needs to be education given to expecting parents, about adult and child nutrition.  There also needs to be a large focus on removing the so many unhealthy vendors and food choices that exist around the country.  

Overall, I think our money spent at the present time is allotted correctly.  In the future it will probably have to change, but for now, it would be extremely wasteful.

Justice is described as “the fair disbursement of common advantages and the sharing of common burdens” to improve population health and help the disadvantaged (Gostin). This mentality has led to policies focused on providing medical care services. In fact, based on your readings, 95% of US health service spending goes towards direct medical services, but only 5% is invested in prevention. Is this the best approach? What do you think policymakers should focus on to reduce health disparities?

I wouldn't plan to spend these large amount of money to come to USC and study public health if my goal is not to reduce the disaprities that we have in the United States. Today's fast speed society, people have no patience to wait and see a 10 - 20 year of studies about something that might not be proven. It is easier if to solve the surface of problem by giving people the instant treatment. The root of the problem is usually neglected, it is probably because of people's mentality of not to see the "real problem". Health disparities include a very complicate combination of problem through education, economy, politics, and today's moral trend. These complications are chain to each other and affect each other direct or indirectly. I strongly believe prevention is the key way to solve the root of health care problem and it is a much more efficient and cheaper. However, direct medical care service is easier to implement since it doesn't involve any complication. In order to fight this wrong mentality of "too lazy to fix the real problem", we, the public health people will need to fight the right for the budget for the prevention. In addition, I think education starts from kindergarten or early elementary school year will be one of the best methods to prevent many kind's diseases as the children grow older. It will take half or a full of generation to see the difference, but it is worth it!

When It Comes to Policymaking...

Spending on health services should be split equally between prevention and direct medical services or at the very least, there should be more money allocated for preventive services. What many don’t realize is that there are numerous underlying factors that determine illness/injury. Many believe that access to services is a necessary component of health care and is the reason for such poor health outcomes. Policymakers should really look into other factors that attribute to health disparities such as education, housing, income security, nutrition, and environment. A shift in the focus on health care services from restorative to preventive medicine would not only save patients and health care providers more money, but it would save millions of lives. The downside is that results are not immediate. Studies show there are 5 simple preventive services that would save more than 100,000 lives each year in the United States.

LOW USE OF PREVENTIVE CARE COSTS LIVES

Utilization rates remain low for preventive services that are very cost effective and have been recommended for years.
· Daily aspirin therapy to prevent heart disease.
· Smoking cessation: An additional 42,000 lives would be saved each year by increasing to 90% the portion of smokers who are advised by a health care professional to quit and are offered assistance. Currently, only 28% of smokers receive such services.
· Colorectal cancer screening: Another 14,000 additional lives would be saved each year by increasing to 90% the portion of adults aged 50 and older who currently receive any recommended screening for colorectal cancer. Today, fewer than 50% of adults receive these services.
· Flu vaccination: An additional 12,000 lives would be saved each year by increasing the portion of adults aged 50 and older who get an annual flu vaccination to 90%. Only 37% of adults currently get an annual flu vaccination.
· Breast cancer screening: An additional 3,700 lives would be saved each year by increasing to 90% the portion of women ages 40 and older who have been screened for breast cancer in the past 2 years. Today, 67% of women have been screened in the past 2 years.

Health: Our Social Responsibility

Prevention of disease is an extremely complex and fundamentally challenging topic to broach, particularly in the United States.  In todays world, we continually search for instantaneous solutions to complex issues.  When sickness strikes, we look to doctors and pills as magic bullets for disease burden. When it comes to disease, we all want to believe that we're immune from any obtaining any sort of illness or horrific disease until we are in fact stricken. 

Despite this belief and regardless of genetics, diet, or otherwise no one is above illness.   This is why in order for the country to begin a transition period into a more socialized approach to health, we as citizens MUST take out a greater personal stake in our own health.   Health is something that must be continually strived for a daily basis. Expecting the government to implement a blanket health system and provide more preventive health measures is ludicrous considering we continue to maintain a lack of accountability in our own health (i.e. cigarette smoking, poor dietary patterns etc.). 

It is entirely ridiculous to say that the government should provide more preventive measures when we, ourselves, fail to take responsibility for our health.  Until a fundamental shift occurs in which we fully believe in the supreme autonomy and accountability of the human being, no "magic bullets" should be expected, nor deserved.  

When It Comes to Policymaking...

There is no question that direct medical services provided by hospitals and physicians are vital for the health care system- let's face it without it people would die. But I think a lot can be learned from professor Gostin's quote. The the U.S. Health Care System puts a tremendous strain on direct medical services. There does not really seem to be a fair "sharing of common burdens". Rather it seems that a disproportionate amount of power is given to direct medical services (95% direct medical services to 5% prevention). This certainly is not the best approach. I think for a long time, medicine has encompassed the process of providing medical services to those in need. Effectively, this system has given rise to on the spot treatment services for those who have no other choice. Moreover, our nation's hospitals and clinics are filled with people who have lived unhealthy lifestyles for all their lives and have been aloof to health education altogether. There certainly needs to be a massive addition of health education into society. But it is not enough to simply educate the public about pap smears and immunization- they must be mobilized to take action and encouraged along the way.

I think its really important to understand that preventative medicine does not simply mean immunizations and pap smears; eating healthy, making more conscientious decisions about one's body, and exercising are all excellent ways to effectively prevent the onset of future health issues. Even instilling health promotion campaigns which incorporate these rudimentary elements would go a long way in preventing numerous illnesses.

Prevention is so Simple...

I like how all of these blogs tie into one another. Ultimately, it's all about the money... as depressing as it may be... the more we read into it... it's about the rich getting richer by having the sick get sicker through the means of limiting the resources necessary to acquire the knowledge of disease prevention, in this case, health education and disease prevention approaches. Consequently, there's health disparities across the board (race, gender, age, SES, etc). It's sickening to see that this is the society we live in.

Given the current state of our health care system, it seems pretty evident that the system is simply not working and is far from delivering services in a just manner. Far too many people are uninsured, which in turn prevents them from utilizing primary care physicians for regular checkups. The only time they seek medical attention is when their situation is serious enough that prevention strategies are no longer plausible. This then contributes to our nation's skyrocketing medical expenses and the general decline in the health of the population. A generally unhealthier population means less healthy people in the workforce, which contributes to a decline in the economy. All things considered, it seems that the 95% spent on direct medical services versus the measly 5% spent on prevention is not the most efficient way to fund the health care system; more funding should be given towards preventive medicine. This will, however, take much time before the rewards will be seen since the effects of preventive measures can only be seen in the long run through the decline in disease prevalence amongst the population.

To ensure that everyone has an equal opportunity to access the most basic health care, I believe that it is important for the government to place insuring the uninsured at the top of their priorities list. It is no shock that higher rates of disease burden is felt amongst those with the lowest SES since a majority of them are uninsured. Insuring them would allow them the means to be able to utilize primary care physicians for their regular checkups as opposed to using the emergency department, which do not offer a continuity of care. Although this may seem a bit far-fetched, perhaps giving medical students more of an incentive to practice general medicine as opposed to specializing would be another means to reduce health disparities. Since there are far too many specialized doctors compared to the needs of the population, there aren't enough general practitioners, especially in those areas that need them the most. Most doctors, if given the choice, would probably choose to set up their practice/clinic in a well-off city as opposed to a "ghetto" neighborhood. Hence, those who do live in the "ghetto" still have to travel farther distances just to pay a visit to their doctor. Giving medical students an incentive to set up their practice in a more socioeconomically disadvantaged community would help to alleviate some of the inequalities in access to care.

And Justice for All...

"In the end, the field of public health is caught in a dilemma. If it conceives
of itself too narrowly, public health will be accused of lacking vision.
It will fail to see the root causes of ill health and will fail to utilize
the broad range of social, economic, scientific, and behavioral tools necessary
to achieve a healthier population. If, however, public health conceives
of itself too expansively, it will be accused of overreaching and
invading a sphere reserved for politics, not science. The field will lose
its ability to explain its mission and functions in comprehensible terms
and, consequently, to sell public health in the marketplace of politics
and priorities."
-Professor Lawrence O. Gostin
"A Theory and Definition of Public Health Law in Public Health Law Power, Duty, Restraint"
September 2008 - Georgetown University Law Center

After skimming through some of Professor Gostin's writings on the issue of Public Health Law, I am fully aware that my comments will not do this topic "justice" - but I will try. There is a message that Professor Gostin seemingly resonates throughout his paper: the field of public health walks a very thin line. It is neither economics nor politics; it does not fall under medical services, but may lean upon its shoulders from time to time; it undoubtedly requires support from the field of R&D, but won't exhibit its benefits/failures until the findings have been implemented and seen to stand the test of time. Ultimately, with so many tangibles intertwined with the field of public health, it may have trouble finding its own identity.

Professor Gostin's description of justice is profound, but finds itself far from being attained with respect to the current climate of health care policy in the United States. Part of America's promise shaped in the past few decades has been the guarantees of economic freedoms to her citizens, assuring them that government will keep its hands off their wallets and allow the spirit of competition, the market place, and hard-work be the driving forces for success. It is the culture we find ourselves in today. It is what public health must adapt to, work with, and be able to use its far-reaching powers in order to shape and change that culture accordingly. Increased funding for public health and prevention is an approach, but not a solution. Public health must help drive a notion that health care should not just be perceived as an individual responsibility, but a social task involving multiple classes, individuals with various occupations, and ultimately have ambitions to educate the target audience with regards to what their health means and how it can be managed. Policymakers must be able to not only lead, but listen! Listen to those who feel excluded from "justice"; listen to health care providers, economists, the public and private sector, and the education sector; listen to individuals like Professor Gostin, who've spent better parts of their lives on issues such as this. Maybe if policymakers realize they don't know as much about the issues as they think, it can be the first step of something REALLY BIG!

95 to 5

When looking at this chart, it's almost certain that we complain public health to be such a small piece.  For sure we want to enlarge this part, but how?  Where should we take money from?  Shall we redivide this pie to make public health larger or allocate additional investment only on public health?  I think both would be hard.

Within the national health expenditure, we can see clearly that most of the spending goes to medical care and services.  Retreating money from these parts seems unwise unless efficiency and technology is improved to lower the basic cost of services. 

So what about drawing money from other sections of federal budget?  Perhaps we could take a little bit from defense....

From the aspect of investment, prevention spending differs from others that it has no instant return.  It's a long-term process.  I guess that's why it is difficult to shift money to prevention since there're so much spending on immediate needs and we can't just cut their costs.  Like if I say we could save $5 in medical care spending after 10 years in the future when only $1 is spent in prevention now, where does that additional $1 come from in the next 9 years?  Are policy makers willing to spend that $1?

ARE YOU WORTH THE MONEY??

It’s obvious from going to any government office that it takes forever to get things done. It involves a lot of paper work and the government will not invest money in a new program or programs unless there is a consensus among both republicans and democrats (those in power) that what we want is really going to be fruitful or deserving to those that will be receiving the services such as SCHIP, Medicaid, Medicare. Now, in terms of preventative medicine all Americans are deserving of making informed choices about what they eat, their environmental, and any other life choices that directly affect their health in the long run such as preventative screening. However, truth be told cost-effective preventive measures are only cost-effective in certain circumstances such as Haemophilus influenzae type b vaccination of toddlers, One-time colonoscopy screening for colorectal cancer in men 60–64 years old, Cognitive-behavioral family intervention for patients with Alzheimer’s disease, Cochlear implants in profoundly deaf children (as published in The New England Journal of Medicine link: http://content.nejm.org/cgi/reprint/358/7/661.pdf
So we as public health newbie’s have a responsibility to track/compile the data and show those in office (politicians) that the money spend will be fruitful its just a matter of time before cost-effectiveness can be seen.

If Nothing is Broken WHY Fix it

Most people tend to have the mentality that if there is nothing wrong than there is nothing to fix. This means that the purpose of going to the doctor is to fix something that has gone wrong, but if nothing is wrong than there is no point to go to the doctors. For most people attending a doctor’s appointment means losing money because they have to take time from work. When they are sick getting better and seeing a doctor outweigh losing a day of work, but losing money for a routine checkup of something that does not exist may not seem worth it.
It almost seems intuitive that to get the most for our buck we would invest in prevention to avoid the high prices of medical care. Prevention entails changing many of people bad habits, but people may not be willing to do this until they see a negative consequence to those actions.
Prevention is very broad and includes many different aspects. Education is a big part of prevention and should be more enforced to everyone equally in America. Screening tests are also a very important component of prevention, but they are not being used at the rates that would be considered ideal. Prevention is needed to improve healthcare, but it is not the only thing that needs to be modified.
Policy makers need to focus on where the money is being is distributed to and whether it is being used wisely. Hospitals seem to have a disproportionate amount of money coming in, but still the services provided in the ER are not ideal. More time, money, and effort needed to be put into preventing illnesses and therefore preventing the extraordinary amount of money being spent on medical care.

Freedom to be fat

It's true that many Americans would make better choices about their health if they were more informed about preventive measures, however I think the majority of people would continue carrying on with their unhealthy ways.  Americans love feeling in control of their actions, something of a "I deserve everything I have" type of motto which can be positive in some aspects but also negative when you're looking at poor health choices.  No one likes being told what to do, myself included, however some people don't have the resources to make better decisions about their health.  I remember seeing on the news one day about a year ago that part of Japan's (one of the healthiest countries worldwide) health policy was to measure every single person's waist size to see if they were too fat according to some standard.  If a government agency came into my work and told me it was required to let them measure my waist line I would think they were crazy.  Even if the policy resulted in an eventual "greater good", I don't know if I would be comfortable with that kind of practice.  I love being able to gorge on a big mac or two at almost any time of the day, at any random corner of the universe, but if McDonald's somehow disappeared overnight I wouldn't cry for too long.  Some people just aren't going to, or can't, make good health choices for themselves which results in acute and chronic health conditions that we all end up paying for one way or another.  Unless we loosen the anti-socialist collars that the majority of Americans seem to own, we can't expect drastic changes to happen overnight.         

Are we preventing or simply responding?

Personally, when I take a step back and think, "Ok, what besides insurance needs to change about health care in this country?" my conclusion is nearly always: There has to be a shift from a simply responsive system to one that focuses on prevention from infancy.

Prevention can cover a myriad of fields, and as future public health professionals, I think that we are at the forefront of the future of health care, and where it needs to go.  How do preventive practices get incorporated into the whole of life?  Public policy.  Someone has to take the scientific discoveries and knowledge and make them mainstream.  Whether that means streamlining and making courses of medical treatment consistent no matter where one lives or how much money they have, or whether that means having a few reliable sources where people can look for accurate health information, I don't know.

What I do know is that the vast majority of Americans don't know they are unhealthy until something serious happens -- until they have symptoms.  What if they had been receiving consistent health care their entire lives, even when they were in their mid-twenties and thought they were invincible?  What if they were armed with a constantly updated, easy to use source they could consult about every issue from stress to exercise to safe sex?  Maybe, just maybe, we could bring down the rate of some of these chronic diseases that are largely preventable.

I used to work in clinical cardiology research, focusing on treatment of cholesterol levels as a way to prevent future heart attacks and strokes, and I was constantly amazed by how little these patients knew about what they could actually change and why it would be good for them.  SO much of our American culture emphasizes fixing problems once they have occurred, rather than preventing problems from occurring, and therein lies the root of a large number of our health issues.  And actually, a lot of our other problems too.  I'm not an expert, but I really think that policy change needs to start at the very base of the system -- in other words facilitating that shift from treatment to prevention.  And until medical schools start training new physicians in that manner and some reform happens in the way medical care is paid for, none of this will really have a chance at success.  Maybe Obama can help!

The Devil's Advocate: Apples and Potato Chips

Before we leap to the conclusion that more preventative medicine will result in better health, I think we need to step back and carefully define what we mean by "preventative."

Many of the "preventative" clinical measures I've encountered in the literature or media are not actually preventative but diagnostic. They are geared towards detecting a health problem early so that it can be resolved before it develops into something much more debilitating, complex, and expensive. These measures, which usually consist of things like Pap smears, mammograms, blood pressure and glucose level tests, etc., are essentially assessments of health risk that can inform more timely interventions. While I don't deny that this is a step towards improving our overall health status, the difference between a health care system with "preventative" focus versus one with curative focus seems to be the difference between finding out that you're at risk for heart disease and getting a coronary bypass. Though the former is an improvement over the latter, neither addresses the source of the risk. Neither prevents the risk in the first place.

If curative medicine asks, "how do we fix it?", then this diagnostic version of "preventative" medicine is simply asking, "what is it?" at an earlier time. A genuinely preventative approach would instead ask, "why is it there to begin with?" and immediately after, "how do we prevent it from happening?"

These two questions, however, pose an even greater problem. Curative medicine is easy to define. So is diagnostic medicine. Both fit neatly within the realm of medical science. Preventative medicine, in attempting to not only answer the question of why a disease process begins in the first place but actually influence those risk factors, is overstepping its bounds by an enormous margin. It's success is impeded not only by the inefficiencies or limitations of our current system, but by the fundamental nature of health itself: it encompasses everything in our lives. Should doctors or government officials be telling us what food to buy, when to shower, how long to sleep, what air we should breathe? Should they discourage us from taking up stressful jobs, staying up late to study for our classes, or traveling? In our assigned reading this week, Lantz cites an "intervention framework" to improve population health that includes nebulous and lofty objectives such as "increasing opportunities for self-fulfillment," "strengthening community cohesion," and "increasing socioeconomic well-being." I hardly know what these mean in practical terms, but it sounds like public health is meant to develop policies to improve "everything about life in general."

Perhaps it is not fair to address this from a personal angle. Perhaps preventative medicine is actually trying to target commercial or public entities, such as restaurants, gyms, or air quality control committees. After all, the FDA is a public health entity that is constantly struggling to ensure that Americans are offered the safest foods of the highest quality. Perhaps one practical solution would be relatively straightforward: give the FDA some more of our tax dollars.

But let's think for a moment of how a public health entity (even one with as much clout and presence as the FDA) would begin to tackle something as simple and intuitive as promoting healthier eating choices. Never mind the pricklier socioeconomic determinants--we just want the families of, say, Pasadena to buy more apples and less potato chips.

What can the FDA do? It can mandate that the potato chips include a nutritional label that spells out its fat and caloric content. It can educate school children that apples are a healthier choice. It can even go as far as to subsidize the purchase of apples for the poor. But no matter how much it regulates or educates, it will never be able to do three things: 1) take away a person's choice to buy potato chips; 2) take away a grocer's choice to stock them; and 3) make apples easier and cheaper to produce than potato chips.

Have you ever wondered why apples (and the whole produce section) is always located along the side wall of a supermarket, why potato chips are always in a center aisle, or why milk is always at the back? It's because decades of market research, thousands of very intelligent sociologists, and millions of dollars have led to the discovery that 1) Americans regularly and frequently buy certain food products (such as milk); and 2) we tend to buy more things if we see more things to buy. So grocers make sure that we must weave through their store to get to the milk in the back. In the course of our weaving, we see the potato chips. Why are the potato chips there? Because food companies are required to pay a "slotting fee" to stock their items in certain spaces in grocery stores. Supermarkets rent out their shelf space, and the prime real estate is always taken by those food companies that are large enough and rich enough to pay. This is why candy bars are always stocked near the cash register, and why potato chips always appear at eye level. Why are apples located at the periphery? Because supermarkets always stock perishables (meat, seafood, produce) along the walls, so that people will be forced to walk through the center aisles (the non-perishables) to get to them. Incidentally, non-perishables have a much larger profit margin than perishables (the latter need more care to transport, clean and maintain).

Now, if the FDA really wanted to bring this marketing machine to a halt (force supermarkets to stock potato chips somewhere else, for instance), it would need to do something very unconstitutional and very much outside of the powers granted to it by the people. Problems like this, I think, explain why preventative medicine has never risen to the forefront of healthcare delivery. Health is everything. It is our economy, our social hierarchy, our childhood, our environment, our way of life. No one sector of our society can stick its nose in everything else. This is not to say, however, that there aren't certain preventative measures that are realistic, widely applicable, and extremely beneficial (vaccinations, for instance). However, I feel that regulatory measures are, in general, not the solution. A better approach might be to focus on health information transparency and simply inform people of the choices that are available to them or the dangers posed to their health by certain events or environments, and leave it at that. It is not the place of any government entity (however well-meaning or well-informed) to determine for us what is best for us. It should simply make sure that we have the opportunity and the right information to decide for ourselves.

this is the second notice that the factory warranty on your vehicle is about to expire

Prevention Detention: The Poem

Rolling down the street in my new car

I dont want it to break down, I want to go far

So I feed it good fluids, and get it checked up

By a professional who knows, everything what's up

Make sure it runs well, I dont want to get stuck

In the middle of nowhere, to get towed by a truck

Wouldn't you rather pay now, get all that stuff done

Instead of at the end, when your car might not run

You'll end up paying more when the problems arise

When you could've paid less, for the price of french fries

Maintenance is key, you better believe

Your car will live longer, that should help you relieve

Yes, that poem is talking about car maintenance.  But who says, that maintaining a car is not pretty similar to health care?  We already talked about how health insurance is quite similar to car insurance, right?  All this money that is being spent on direct medical services, but only a small, tiny portion is being directed towards preventive measures.  Now I'm not saying that we should split it 50/50, because direct health care is still an important part of this entire system.  However, we must think that more there should be more emphasis on the prevention portion.  Prevention is definitely not going to be the cure-all for our society, but it can certainly help the overall goal.  

When we talk about prevention, there are many things we can assess as being "prevention."  Are we talking about providing the public with the knowledge to reduce their risk of preventable death, such as from smoking, obesity, alcohol consumption, std's, and car accidents?  Or are we talking about prevention in the form of blood pressure and cholesterol screening?  When we're talking about the latter, keep in mind that we're only detecting diseases earlier, not actually keeping them from happening.  For example, finding cancer in its early stages is much easier to deal with, as opposed to a cancer that has already spread through much of the body.  Screening for diabetes can be helpful if found early on, so that the patient may still have ample time to take lifestyle changing action.  When addressing the former, the United States ranks at the bottom of the league in preventable deaths.  Focusing on teaching the population a lifestyle change will help in that category.  Our government does not need to dive into the deep end of this prevention topic, but it needs to implement uniform preventive practices throughout the country, and it will definitely pay dividends down the road.

Give a man bread, and he can eat for a day.  Teach a man to fish, he can eat for the rest of his life.  Give a patient treatment for a disease, they will feel better for a while.  Teach a patient to take care of themselves and indulge in a healthier lifestyle change, they will feel better for life.  That's whats up.

Tis why we are here

We have all seen the statistics that indicate the highest mortality rates every year in the last couple years are heart disease, stroke, cancer, and diabetes.  All of these are in essence a chronic disease and can be preventable.  Most of the increasing healthcare costs have a lot to do with the increase of all these preventable diseases yet the government continues to funnel money into non-preventive avenues.  In this fast paced society, it's not wonder.  The impacts of preventive medicine are rarely seen in easily proven timely instances.  In this society, results need to be seen now, immediate, and proven to work.  Preventive medicine, however, takes time and results are usually not seen till many years later if and only if the "patient" actually does the necessary lifestyle changes to prevent or backtrack a chronic disease.  At the same time, if the government were to funnel a lot of money into preventive medicine, in the short term, tax payers will probably feel the money is going to waste since they themselves can't see results right away.  The entire situation turns into a vicious cycle.  The only way to break the cycle is to convince others that preventive medicine is really the way to go.  It is only the first giant step in persuasion toward preventive medicine that will be followed by many many more instances of needed persuasion and change of attitude toward preventive medicine.  It's difficult, but the more people for it, the more of a chance we got.

Unnecessary spending & unequal dispersion

Looking at the pie chart to the right, we see that hospitals take up a big chunk of national healthcare spending. Not that hospitals don’t need the money—it is expensive to manage and keep a hospital running—but a lot of times they are not run efficiently. People go into the hospital when they really don’t need to, and that costs money. Like we discussed before in class, many people get doubly-immunized simply because their immunization records could not be found…and that costs money. A physician who’s unproductive or makes a bad call in diagnosing a patient will also cost the system a lot of money. There’s a lot of unnecessary spending going on within the healthcare infrastructure.

I think we should also be concerned about who exactly is receiving healthcare and prevention services. More often than not, the low-income population is not getting either. And if they are receiving healthcare, the quality of the services they receive leaves much room for improvement. Oftentimes, education (schooling) itself is a form of prevention, and that is something which those with low SES simply don’t have. Even if they are insured, that still doesn’t guarantee these people quality health care, or even access to it. Just because nationally we spend trillions of dollars to pay for health care doesn’t mean that everyone is benefiting from it, which is hardly “justice”…I guess it sounds better in ideology than in practice.

Prevention is Better than Cure-- but, is it enough?

Preventive care is crucial to an effective health care delivery system. When utilized appropriately, preventive care services such as Pap tests, mammograms, flu vaccinations, reminders for preventive care visits, and discussions of emotional and lifestyle issues can increase the effectiveness of care through the early diagnosis or prevention of illness.

I think to reduce the health disparities, just investing in preventive care alone is not enough any more. Policy makers should not focus just on investing more in preventive medicine. Equally important will be improving and sustaining its ability to promote healthy lives, and on the provision of care that is safe and coordinated, as well as accessible, efficient, and equitable.

This is because, according to the pie chart from CMS, we are said to spend only 3% on preventive medicine. But, latest study done by "The Common Wealth Fund" showed that compared with the other five countries like UK, Canada, Germany, Australia and New Zealand, the U.S. actually fares BEST and rank #1 on provision and receipt of preventive care, in a dimension called "right care."

However, its low scores on chronic care management and safe, coordinated, and patient-centered care pull its overall quality score down.

The bottom line is that we have the best science in the world and have competitive edge. But, we don’t have the best health care system in the world to maintain it.

The study was published by Davis, Schoen, Schoenbaum et al in May, 2007 issue of The Commonwealth Fund report.

Please check “Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care” for more details about the study.

Health Education leads to Policy Change

When we evaluate the amount of money spent in our hospitals to take care of our patients, it is easy to understand why so many of our doctors are considered the best in the world. Johns Hopkins, Harvard and Washington University in St. Louis, just to name a few, consistently develop physicians that are expected to be better than the rest. What makes our system backward is not the quality of care; it is its distribution. The best care can be bought for inordinate amounts of money, but to look at the problem fundamentally, why are we spending 95% of our money in treating people if prevention can eliminate costly medical care to begin with? With health conditions becoming increasingly prevalent, it is difficult to imagine a scenario where money would be taken away from treatment. When we look at the primary causes of these costly procedures and medications and see conditions like obesity and poor hygiene as the culprits, the case for investing more money in health education and preventative medicine becomes much stronger. AIDS education is slowly increasing the number of those who use condoms if sexually active, vending machines have been restocked with healthier options and exercise programs are becoming more and more common in communities. Health education has the power to inform the population about incorrect or unhealthy practices and eliminate their need for expensive care due to complications from conditions that could have been avoided altogether. The public health sector is attempting at informing the public by targeting youth and advocating safe and healthy alternatives to activities and diets their parents may be used to. To overhaul a system that already has an enormous majority of its money spent on treatment would be a futile endeavor. With small interventions focusing on the grassroots and building up to policy change, we can expect much more practical progress.

Requiring a Healthy Eating and Exercise Check-up?

The dental field is intricately linked to health care… if not one in the same. A major breakthrough with dental health came in the way of fluoridating city water systems. Dental researchers have shown that just introducing fluoride into a (previously unfluoridated) city's drinking water supply can reduce its inhabitants' rate of tooth decay between 40 and 70 percent. At a minimum cost to the city, patients (particularly children) will have less decay and hundreds and thousands of dollars will be saved with every patient. Furthermore, educating people about the importance of flossing and brushing (which are all preventative habits) also save patients tons of money. The same can be done in terms of educating people about the importance of eating healthy and exercising. If aggressive strides were made in getting patients to eat healthy and exercise regularly I am sure the rate of cardiovascular disease for example will come down dramatically.

Unfortunately we live in the real world and requiring physicians to give yearly “healthy eating and exercise” check-ups will be hard to enforce… But I believe as a health professional, we can all push for a requirement for all patients to get a yearly “healthy eating and exercise” check-ups.

For example, a policy I could think of is: States and the federal government can require a Healthy Eating and Exercise Check-up as a requirement to attend high-school…these children can grow up to be healthy adults and even educate their parents. Don’t see this happening anytime soon, but one can dream right?

When It Comes to Policymaking

It seems that the issue of prevention has come into greater focus recently, as the US healthcare system has come under more scrutiny. Most people seem to agree that preventive measures are not only important from a medical and individual-health perspective ("an ounce of prevention is worth a ton of cure"), but could also be key in reducing the massive amount of money that is being spent on health care in this country. Looking at the pie chart above, we can see that 31% of health expenditures are going towards hospital care, and 10% to prescription drugs. While a large portion of these costs are probably necessary and justified, a great deal could probably be avoided by reducing the number of inpatients admitted to hospitals or prescribing drugs only when they are absolutely necessary. Improving preventive practices and screening for "expensive diseases" could greatly reduce hospital visits and would also help reduce the health disparities across SES strata by (for example) requiring all children to undergo screening or health education in schools, and requiring school cafeterias to serve healthier foods etc.

What do you think policymakers should focus on to reduce health disparities?
We are what we eat, so lets work on prevention and education. However, focusing on these is not a smart business tactic, right now. There might be a way for the public to afford to pay health care's treatment sector as well as its prevention sector and do it without getting into debt. It is like paying for two leases on an apartment while moving from one to another.
With an ever increasing number of fast-food restaurants, and certain chains, like McDonald's making record profits, it seems that public health professionals are temporarily losing ground on the battle to make the public healthy. But what could we do in these difficult economic times. It wouldn't be American to simply thumb down an industry, even if its slowly killing the people who buy into it, ("got ciggs?"). But what if policymakers tweak the market so that prevention is a buisness asset instead of a liability? I don't claim to be an economics expert but I think that the best way to reduce health disparities is to create a market that benefits businesses to encourage public "healthiness." Lets ride the free-market wave so that fast-food restaurants could not resist preparing healthier foods or small business owners see a real benefit to have health employees. We could drastically cut back on morbidity, cut back on hospital usage, and on prescription drugs. This method has to work, right? Free market is the American way and its high time the public health industry realizes this is the key.