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.
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