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Strange voices in the land
PREVENTIVE
MEDICINE
6, 462-465 (1977)
EDITORIALS Strange
Voices DANIEL
in the Land
G. MILLER
Preventive Medicine InstituteStrang Clinic, 55 East 34th Street, New York, Ne\cl York 10016
In recent months strange voices have been heard throughout the land. Together they are a chorus singing a threnody for prevention. Zfem: An editorial in the Journal of the American Medical Association criticizes professionals involved in programs against smoking, hypertension, high fat consumption, and the use of seat belts. It goes on to say, “Enough is enough. Let the rest of us enjoy ourselves-direct your talents to more productive medical endeavors,” by which I presume the author means activities such as intensive care units, cardiac bypass surgery and the like. Item: The New England Journal of Medicine carried an essay in its ongoing series, “Notes of a Biology Watcher,” which sings a Byronic paean to the strength and resilience of the human body and derides preventive medicine as a nonexistent specialty. Item: The New York Times publishes a polemic against the periodic health examination in the form of a skewed selection of citations to support the author’s viewpoint, and contends that since there is nothing we can do to protect ourselves against disease, we might just as well wait until symptoms appear and then apply for medical care. This physician author goes further and actually impugns the motives of physicians responsible for carrying out periodic health examinations. Coming from a member of a profession which has not learned to avoid unnecessary surgery or the prescription of worthless medication, this only invites invidious comparison. Item: A congressman pleads that our legislators do nothing to interfere with the tobacco industry lest serious economic dislocations occur. Item: A well-known government economist muses on the terrifying consequences of a truly effective preventive medicine program; the integrity of the Social Security Fund would be threatened. Right to life, liberty, and the pursuit of happiness? Jefferson wrote that the primary purpose of laws governing society was safus populi. We have come a long way from this ideal of Jeffersonian democracy. These waves of doubt and criticism lash against an indomitable wall of facts. Cancer, heart disease, and accidents are the chief causes of premature death in this country. For those forms of cancer comprising over 70% of cancer fatalities there is a currently available means of early detection or prevention which would either eradicate the disease or lead to 50% or greater increases in 10- and 15-year survival rates (9). Similarly, carefully evaluated studies have demonstrated that the elimination of cigarette smoking, obesity, and hypertension will diminish premature deaths due to heart disease. Seat belts keep fractured skulls and mangled 462 Copyright 0 1977 by Academic Press. Inc. All rights of reproduction in any form reserved.
EDITORIALS
463
bodies out of the emergency rooms where our distinguished and skilled colleagues would have us wait complacently for the arrival of these “interesting cases.” Herculean efforts to keep patients with advanced cancer alive an additional 3, 6, or 12 months with intensive combinations of chemotherapy are vigorously encouraged and no one ever mentions that the patient need not ever have arrived at that sorry state. Yet less than 10% of the funding allotted in the current National Cancer Act goes for prevention or detection efforts. The aforementioned epidemiologic studies are strong signals directing us to the goal of preventing premature mortality. The problem is to translate those epidemiologic signals into effective programs. To achieve this we need programs conducted by critical methodologists and evaluators, and advocates to present effective programs to policy makers. Guidelines for program design and evaluation have been laid down by Lilienfeld (8); Dales et al. have published the details of the evaluation methodology employed in the Kaiser-Permanente preventive medicine program (3); Olsen et al. have pointed out the pitfalls in employing a screening program not linked to medical follow-up where there is “a collusion of indifference between patient and physician” regarding the outcome of testing (10). Sackett and Holland have set forth the necessity for carefully defining goals, strategies, and decision making in programs for disease detection (11). There has been renewed interest in the potential of health education in preventive medicine programs in the wake of the controlled studies of Green and co-workers (5,6). Acton has expanded the concept of cost-benefit analysis when applied to health problems involving community decision making (1). Sutnick et al. have described an elaborately designed risk factor program for early disease detection that incorporates health education and has evaluation and accountability as part of the design (12). There are single-site detection programs being evaluated for coronary heart disease, hypertension, cancer of the breast, lung, and colon, and others. These have been carefully structured and are being closely monitored and evaluated. The results of these programs will have public health impact for years to come since the time, energy, and funding involved make it unlikely that they will soon be repeated. What will ensue from such studies will be early detection and prevention programs considerably different from the periodic health examination as it is conventionally defined. The content will differ; it is likely that the examination will no longer be exclusively carried out by a physician, and to the degree that it is funded by government and industry, it must be accountable in terms of benefits derived. One early casualty, mourned by no one, will be the performance of mindless batteries of biochemical and mechanical tests. The argument that more tests can be done at less expense is outweighed by the cost, anxiety, and inconvenience resulting from the large number of false-positive findings (2). No test should be carried out unless it has an acceptable level of sensitivity and specificity for the disease it screens for; no disease should be included in the screen unless its diagnosis is clearly of benefit to the patient. However, the most scrupulously designed early detection and prevention program will not have an impact on the health of the public unless it is utilized by the population at risk. Program urilization-here is a challenge as great as that of
464
DANIEL
G.
MILLER
program design. How can you get the population at risk and prevention programs, and follow recommendations?
to utilize early detection What is the role of government in encouraging participation or subsidizing public health programs for noncontagious diseases? What is the precedence? Certainly rickets and caries are not contagious menaces. Yet vitamin D is added to milk and fluorides are routinely added to the water supply. Still these measures do not visibly infringe upon our personal lives. We are not directed to do anything; it is not inconvenient or uncomfortable and there is no direct cost. Can government oblige us to submit to examinations or perhaps treatment? Government and other groups already do. The moment we are born, silver nitrate is placed in our eyes as prophylaxis against gonorrhea1 conjuctivitis. We cannot go to school without a completed health certificate; we cannot get married without an examination for venereal disease; we cannot drive without a vision test; often we cannot get a job without a preemployment physical examination, and cannot get into the armed forces without an extensive series of physical and psychological tests. Almost all of these things happen before we are 40 years of age; to determine whether we are fit to go to school, fit to marry, fit to drive, or to hold a job. It is proper that these “rites of passage” should be linked to examinations for the prevention and detection of treatable disorders. But these “rites-of-passage” examinations should continue into the fifth, sixth, and seventh decades and should be tied similarly to desirable social benefits. This should not be done with a penalty for omission, but in terms of increased benefits as a reward for participation. Public opinion polls (4,7) have shown that about half the adult population is or can be motivated to participate in early detection and prevention programs. The remainder is resistant. Participation must remain voluntary but be encouraged by respected authorities. Furthermore, education for participation and compliance must start young and be continuous. The most difficult to educate will be the medical troglodytes who seldom venture from the caverns of their institutions and historically are indifferent to disease prevention. But there is hope. The percentage of adults smoking cigarettes is starting to decline. About 25% of drivers use seat belts regularly. This is 25% more than did so a generation ago. Seat belts are saving lives; driver education pays off. Education for prevention pays off. Every engineer knows the value of preventive maintenance; the machinery of our industrial society would crumble to a halt without it. The medical romantics enjoin us to enjoy life until illness strikes-as if health protection contravenes an enjoyable life. But such exhortations can be answered with a Byronic analogy. Preventive medicine in this country is the Prisoner of Chillon, narrowly confined, treading a circular path. To free the prisoner we need validated programs, legislation to deliver these programs, and a population educated to use them. Let’s get on with the job. REFERENCES I. Acton, 3. P. Evaluating public programs to save lives: The case of heart attacks. R-95O-RC, January 1973. Rand, Santa Monica. 2. Bailey, A. Biochemistry of well populations. Lancer 2, l436- 1439 (1974). 3. Dales, L. G., Friedman, G. D., and Collen, M. F. Evaluation of a periodic multiphasic health checkup. Methods Inform. Med. 13, l40- 146 (1974). 4. Gallup Organization. Inc. “The Public’s Awareness and Use of Cancer Detection Tests.” Study conducted for the American Cancer Society, Princeton, New Jersey, January 22, 1964.
EDITORIALS
465
5. Green, L. W. A cost-benefit approach to the research literature. Commissioned paper presented at the Will Rogers Foundation Conference on Health Education, Saranac Lake, New York, June Z-23, 1973. Proceedings edited by George Reader, Health Educ. Monogr. 2, 34-64 (1974). 6. Green, L. W., Levine, D. M., and Deeds, S. Clinical trials of health education for hypertensive outpatients: Design and baseline data. Prer. Med. 4, 417-425 (1975). 7. Lieberman Research, Inc. “A Study of Motivational, Attitudinal, and Environmental Deterrents to the Taking of Physical Examinations that Include Cancer Tests,” Vols. I and II. Study conducted for the American Cancer Society, New York, New York, October 1966. 8. Lilienfeld, A. M. Some limitations and problems of screening for cancer. Cancer (SuppI.) 33, 1720- 1724 (1974). 9. Miller, D. G. What is early diagnosis doing? Cancer 36, 426-432 (1976). 10. Olsen, D. M.. Kane, R. L., and Proctor. P. H. A controlled trial of multiphasic screening. N. Engl. J. Med. 294, 925-930
(1976).
II. Sackett, D. L., and Holland, W. W. Controversy in the detection of disease. Lancer 2, 357-360 (1975). 12. Sutnick. A. I.. Miller, D. G., Samson, B., Dean, D., Kukowski, K. M., Halpern, L., Jeffreys, C., and Bahn, A. Population cancer screening. Cancer 38, 1367-1372 (1976).
MEDICINE
6, 462-465 (1977)
EDITORIALS Strange
Voices DANIEL
in the Land
G. MILLER
Preventive Medicine InstituteStrang Clinic, 55 East 34th Street, New York, Ne\cl York 10016
In recent months strange voices have been heard throughout the land. Together they are a chorus singing a threnody for prevention. Zfem: An editorial in the Journal of the American Medical Association criticizes professionals involved in programs against smoking, hypertension, high fat consumption, and the use of seat belts. It goes on to say, “Enough is enough. Let the rest of us enjoy ourselves-direct your talents to more productive medical endeavors,” by which I presume the author means activities such as intensive care units, cardiac bypass surgery and the like. Item: The New England Journal of Medicine carried an essay in its ongoing series, “Notes of a Biology Watcher,” which sings a Byronic paean to the strength and resilience of the human body and derides preventive medicine as a nonexistent specialty. Item: The New York Times publishes a polemic against the periodic health examination in the form of a skewed selection of citations to support the author’s viewpoint, and contends that since there is nothing we can do to protect ourselves against disease, we might just as well wait until symptoms appear and then apply for medical care. This physician author goes further and actually impugns the motives of physicians responsible for carrying out periodic health examinations. Coming from a member of a profession which has not learned to avoid unnecessary surgery or the prescription of worthless medication, this only invites invidious comparison. Item: A congressman pleads that our legislators do nothing to interfere with the tobacco industry lest serious economic dislocations occur. Item: A well-known government economist muses on the terrifying consequences of a truly effective preventive medicine program; the integrity of the Social Security Fund would be threatened. Right to life, liberty, and the pursuit of happiness? Jefferson wrote that the primary purpose of laws governing society was safus populi. We have come a long way from this ideal of Jeffersonian democracy. These waves of doubt and criticism lash against an indomitable wall of facts. Cancer, heart disease, and accidents are the chief causes of premature death in this country. For those forms of cancer comprising over 70% of cancer fatalities there is a currently available means of early detection or prevention which would either eradicate the disease or lead to 50% or greater increases in 10- and 15-year survival rates (9). Similarly, carefully evaluated studies have demonstrated that the elimination of cigarette smoking, obesity, and hypertension will diminish premature deaths due to heart disease. Seat belts keep fractured skulls and mangled 462 Copyright 0 1977 by Academic Press. Inc. All rights of reproduction in any form reserved.
EDITORIALS
463
bodies out of the emergency rooms where our distinguished and skilled colleagues would have us wait complacently for the arrival of these “interesting cases.” Herculean efforts to keep patients with advanced cancer alive an additional 3, 6, or 12 months with intensive combinations of chemotherapy are vigorously encouraged and no one ever mentions that the patient need not ever have arrived at that sorry state. Yet less than 10% of the funding allotted in the current National Cancer Act goes for prevention or detection efforts. The aforementioned epidemiologic studies are strong signals directing us to the goal of preventing premature mortality. The problem is to translate those epidemiologic signals into effective programs. To achieve this we need programs conducted by critical methodologists and evaluators, and advocates to present effective programs to policy makers. Guidelines for program design and evaluation have been laid down by Lilienfeld (8); Dales et al. have published the details of the evaluation methodology employed in the Kaiser-Permanente preventive medicine program (3); Olsen et al. have pointed out the pitfalls in employing a screening program not linked to medical follow-up where there is “a collusion of indifference between patient and physician” regarding the outcome of testing (10). Sackett and Holland have set forth the necessity for carefully defining goals, strategies, and decision making in programs for disease detection (11). There has been renewed interest in the potential of health education in preventive medicine programs in the wake of the controlled studies of Green and co-workers (5,6). Acton has expanded the concept of cost-benefit analysis when applied to health problems involving community decision making (1). Sutnick et al. have described an elaborately designed risk factor program for early disease detection that incorporates health education and has evaluation and accountability as part of the design (12). There are single-site detection programs being evaluated for coronary heart disease, hypertension, cancer of the breast, lung, and colon, and others. These have been carefully structured and are being closely monitored and evaluated. The results of these programs will have public health impact for years to come since the time, energy, and funding involved make it unlikely that they will soon be repeated. What will ensue from such studies will be early detection and prevention programs considerably different from the periodic health examination as it is conventionally defined. The content will differ; it is likely that the examination will no longer be exclusively carried out by a physician, and to the degree that it is funded by government and industry, it must be accountable in terms of benefits derived. One early casualty, mourned by no one, will be the performance of mindless batteries of biochemical and mechanical tests. The argument that more tests can be done at less expense is outweighed by the cost, anxiety, and inconvenience resulting from the large number of false-positive findings (2). No test should be carried out unless it has an acceptable level of sensitivity and specificity for the disease it screens for; no disease should be included in the screen unless its diagnosis is clearly of benefit to the patient. However, the most scrupulously designed early detection and prevention program will not have an impact on the health of the public unless it is utilized by the population at risk. Program urilization-here is a challenge as great as that of
464
DANIEL
G.
MILLER
program design. How can you get the population at risk and prevention programs, and follow recommendations?
to utilize early detection What is the role of government in encouraging participation or subsidizing public health programs for noncontagious diseases? What is the precedence? Certainly rickets and caries are not contagious menaces. Yet vitamin D is added to milk and fluorides are routinely added to the water supply. Still these measures do not visibly infringe upon our personal lives. We are not directed to do anything; it is not inconvenient or uncomfortable and there is no direct cost. Can government oblige us to submit to examinations or perhaps treatment? Government and other groups already do. The moment we are born, silver nitrate is placed in our eyes as prophylaxis against gonorrhea1 conjuctivitis. We cannot go to school without a completed health certificate; we cannot get married without an examination for venereal disease; we cannot drive without a vision test; often we cannot get a job without a preemployment physical examination, and cannot get into the armed forces without an extensive series of physical and psychological tests. Almost all of these things happen before we are 40 years of age; to determine whether we are fit to go to school, fit to marry, fit to drive, or to hold a job. It is proper that these “rites of passage” should be linked to examinations for the prevention and detection of treatable disorders. But these “rites-of-passage” examinations should continue into the fifth, sixth, and seventh decades and should be tied similarly to desirable social benefits. This should not be done with a penalty for omission, but in terms of increased benefits as a reward for participation. Public opinion polls (4,7) have shown that about half the adult population is or can be motivated to participate in early detection and prevention programs. The remainder is resistant. Participation must remain voluntary but be encouraged by respected authorities. Furthermore, education for participation and compliance must start young and be continuous. The most difficult to educate will be the medical troglodytes who seldom venture from the caverns of their institutions and historically are indifferent to disease prevention. But there is hope. The percentage of adults smoking cigarettes is starting to decline. About 25% of drivers use seat belts regularly. This is 25% more than did so a generation ago. Seat belts are saving lives; driver education pays off. Education for prevention pays off. Every engineer knows the value of preventive maintenance; the machinery of our industrial society would crumble to a halt without it. The medical romantics enjoin us to enjoy life until illness strikes-as if health protection contravenes an enjoyable life. But such exhortations can be answered with a Byronic analogy. Preventive medicine in this country is the Prisoner of Chillon, narrowly confined, treading a circular path. To free the prisoner we need validated programs, legislation to deliver these programs, and a population educated to use them. Let’s get on with the job. REFERENCES I. Acton, 3. P. Evaluating public programs to save lives: The case of heart attacks. R-95O-RC, January 1973. Rand, Santa Monica. 2. Bailey, A. Biochemistry of well populations. Lancer 2, l436- 1439 (1974). 3. Dales, L. G., Friedman, G. D., and Collen, M. F. Evaluation of a periodic multiphasic health checkup. Methods Inform. Med. 13, l40- 146 (1974). 4. Gallup Organization. Inc. “The Public’s Awareness and Use of Cancer Detection Tests.” Study conducted for the American Cancer Society, Princeton, New Jersey, January 22, 1964.
EDITORIALS
465
5. Green, L. W. A cost-benefit approach to the research literature. Commissioned paper presented at the Will Rogers Foundation Conference on Health Education, Saranac Lake, New York, June Z-23, 1973. Proceedings edited by George Reader, Health Educ. Monogr. 2, 34-64 (1974). 6. Green, L. W., Levine, D. M., and Deeds, S. Clinical trials of health education for hypertensive outpatients: Design and baseline data. Prer. Med. 4, 417-425 (1975). 7. Lieberman Research, Inc. “A Study of Motivational, Attitudinal, and Environmental Deterrents to the Taking of Physical Examinations that Include Cancer Tests,” Vols. I and II. Study conducted for the American Cancer Society, New York, New York, October 1966. 8. Lilienfeld, A. M. Some limitations and problems of screening for cancer. Cancer (SuppI.) 33, 1720- 1724 (1974). 9. Miller, D. G. What is early diagnosis doing? Cancer 36, 426-432 (1976). 10. Olsen, D. M.. Kane, R. L., and Proctor. P. H. A controlled trial of multiphasic screening. N. Engl. J. Med. 294, 925-930
(1976).
II. Sackett, D. L., and Holland, W. W. Controversy in the detection of disease. Lancer 2, 357-360 (1975). 12. Sutnick. A. I.. Miller, D. G., Samson, B., Dean, D., Kukowski, K. M., Halpern, L., Jeffreys, C., and Bahn, A. Population cancer screening. Cancer 38, 1367-1372 (1976).