A recent poll found that an overwhelming majority of Americans from across the political spectrum think prevention should be given priority in health reform. Given its intuitive appeal, that result is not surprising. Who could be against the idea of investing in keeping people healthy? But as it turns out, prevention has its detractors. The debate turns on questions about its exact meaning, whether it is cost-effective, and the complexity of the enterprise.
Like most Americans, I am a fan of prevention. My view of what prevention is, however, may not be widely shared. Prevention to my mind means assuring that all persons are able to live in safe, clean houses and neighborhoods; eat healthy foods; socialize with family and friends; get exercise; rest and manage stress. Prevention in this sense is "primary," in that it aims to prevent disease and promote health by creating social and environmental conditions associated with health and well-being. Primary prevention can be distinguished from "secondary" and "tertiary" prevention, although the divisions lack precision. Secondary prevention aims to detect early signs of disease through screening and other interventions to delay its onset or reduce its progression. And tertiary prevention is really management; it aims to reduce the severity of and complications associated with disease.
So, what flies under the banner of "prevention" involves a wide range of actors and activities that take place in a variety of settings, often with quite divergent assumptions and goals. This heterogeneity contributes to debate over whether prevention will save money, as so many politicians claim.
Few health interventions—whether aimed at prevention or treatment—save money. They are investments in a good that people value. Like education and clean air, health contributes to the well-being and productivity of individuals, communities, and society. Health interventions can, however, be cost-effective investments, and whether preventive interventions are cost-effective is a matter of debate. Steven Woolf, a physician and professor at Virginia Commonwealth University, and colleagues have argued that the cacophony of conflicting reports on the subject can be explained in part by technical variations among studies, such as whether costs are examined from a societal perspective or that of a particular sector (such as payers) or posit a short-or long-term time horizon. Of course, some prevention interventions—like so many diagnostic and medical services—are not cost-effective. But this debate, Woolf notes, has overshadowed significant consensus on the worth of a core set of clinical-and community-based preventive interventions, some of which even save money.
Making prevention a principle of health reform faces a more basic challenge. It involves changing human behavior—which is never easy—on two fronts. First, it requires changing health-related habits that have complex developmental, psychological, cultural, and socioeconomic roots. Second, reducing the prevalence of poor health habits will require rethinking how and where health happens. While individuals do sometimes "just do it"—put down the cigarettes or put on the sneakers—behavior change usually requires extensive environmental and social supports that reach across and connect communities, schools, and workplaces. Health happens where people live, learn, love, work, and play. Prevention in the deep, primary sense requires comprehensive urban policy, the commitment of multiple social sectors, and an active, engaged community.
Prevention is among President Obama's core principles of health reform, and if the poll is correct, the American people stand behind him. A majority of those polled reported not only that prevention should be made a priority, but that it merits increased funding. Currently, only 3 to 5 percent of our health budget goes to prevention. However, real gains depend on embracing serious primary prevention. In the absence of efforts that address the social and environmental determinants of health, those who are at risk or sick are very unlikely to improve their health outcomes. Moreover, nothing will slow the rate at which new people enter the at-risk population. Some forty million Americans are projected to join the ranks of the chronically ill by 2030. We can do nothing, or we can work to prevent that future. [End Page c3]