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Prevention and the public health
PREVENTIVE
MEDICINE
13, 323-326 (1984)
GUEST EDITORIAL Prevention
and the Public Health
Prevention is a growth industry in the United States. It is not yet a major industry, but it is respectable enough to be embraced enthusiastically by government, hospitals, business firms, commercial publishers, and segments of the medical profession. Recently, the proceedings of a major symposium involving the corporate world were published in an issue of this journal (5). In the words of one of the conference participants: “Since upper management does not have to be convinced that health and fitness programs are cost-effective, research attention can be directed primarily at inventing new programs rather than proving the worth of old ones” (2). This statement is reminiscent of the ebullient optimism that characterized the turn of the century and spilled over into an unquestioning faith in the value of annual medical examinations as a preventive measure for all ages-now obsolete. Two centuries ago, Johann Peter Frank, in his monumental treatise on the social relations of health and disease, distinguished between two types of preventive medicine, the public (action by the state itself) and the private (action by the physician in his contact with patients) (2). In the real world, the distinction is not always that simple. The programs described in the Connecticut symposium reflect a combination of both approaches. Their focus is on the behavior of the individual, but they are offered by employer to employee with inducements to participate, reflecting group, if not government, approval and pressures. The enormous investment in the London drainage system of 1865 and the aqueducts constructed by Roman engineers are clearer examples of what Frank called “public prevention.” Examples of private prevention can also be drawn from antiquity. One of those most relevant to current efforts is the advice offered by the medical school of Salerno to the King of England in the Middle Ages: The Salerne Schoole doth by these lines impart All health to England’s king and doth advise From care his head to keepe, from wrath his heart, Drink not much wine, sup light, and soone arise Use three physicians still; first Doctor Quiet, . Next Doctor Merry-man, and Doctor Dyet. (8)
Although we have greater knowledge about the causes of disease now, and the specifics of our advice may differ somewhat, our general formula for private prevention (health behavior) has not changed appreciably. The modern public prevention movement (or modern public health) was born in the 19th century. Like the advice given to the King of England, the actions taken were sound, but the reasoning that led to them was unsound. The movement itself was given impetus by the growth of the market economy, the demand for 323 0091-7435/84$3.00 Copyright All rights
8 1984 by Academic Press, Inc. of reproduction in any form reserved.
324
ALFRED
YANKAUER
a healthy labor force, urbanization, and the compelling need to regulate living and working conditions in order to control disease epidemics and to make human life tolerable. It is fortunate that the ecologic fallacy that identified atmospheric miasmas as the cause of disease pointed its finger at sanitary conditions as the source of these miasmas. Like all measures to promote health and prevent disease, the 19th century sanitary reforms were “an aspect of the general civilization of the time and largely determined by the cultural conditions of that time” (9). Much hyperbole and occasional fraud taints some of the current private prevention craze (3). The basis for some of the practices proposed are as unproven as were the bases for the private and public prevention movements of the past; nevertheless, I accept the conventional wisdom: “Although proper living and working conditions will not necessarily prevent all disease, there is no doubt that good housing, proper nutrition, absence of undue emotional stress, suitable working conditions, provision of mental stimulation and physical recreation are more likely to produce a healthy people than poverty, malnutrition, ignorance, decrepit housing and the other social evils associated with ill health” (7). The issue, then, is how to capitalize on current trends. An ounce of prevention may be worth a pound of cure, but, as most people see it, a bird in hand is worth two in the bush; the expected effects of preventive measures are in the bush rather than in the hand. Looking first at public prevention, or government action, we are confronted by some striking paradoxes both at home and abroad. Our own government endorses the concept of prevention with its rhetoric and approves of enforcing state laws which, with great success, have required school children to be immunized against communicable diseases; yet the same government refuses to act against far more dangerous agents of disease and injury, such as cigarettes, handguns, and hazards associated with pollution, occupation, and automobiles. There is some indication, via opinion polls, that there is enough of a consensus in the United States for the government to take stronger action against occupational hazards, air and cigarette smoke pollution, and traffic fatalities, as well as the buildup of nuclear armaments. Failure of the current administration to do so is consistent with its general pro-business, anti-regulation policies: Those laws requiring school children to be immunized do not tread on the toes of commercial interests. Our failure to act here, in the United States, does not seem to be related to our form of government or system of medical care, however. The United Kingdom, whose health system we regard as “socialized,” consistently has refused to pass laws requiring immunization and, as a result, is subject to frequent outbreaks of childhood communicable diseases. In the Soviet Union, whose government we consider an enemy of human freedom, citizens are freely allowed to smoke, drink, and eat themselves to death (1). The People’s Republic of China has stamped out prostitution, alcoholism, and narcotic addiction with the iron hand of the state, but does even less than the United States to discourage cigarette smoking and air pollution, although it has full control of all industries, including the production and distribution of tobacco. These paradoxes suggest that group consensus must be reached before laws
GUEST
EDITORIAL
325
that regulate health behavior and health hazards will be adopted under any form of government. Johann Peter Frank’s prescriptions for almost all aspects of daily living were never implemented, even in his native Prussia, under the most authoritarian of regimes. This is not to say that change in health behavior does not occur, only that it is slow and erratic in its occurrence. The promotion of private prevention can speed the pace of such change. This is a role which Frank himself pointed out quite clearly, and remains an important role for physicians to play today. The prevention-promoting role of the physician can be played in three dimensions: as a doctor who sees patients, as a leader-educator who influences public opinion, and as a scientist who studies the human phenomenon. Unfortunately, the present-day physician is unfit by virtue of his education and place in the social system to play any of these roles adequately. As a doctor who sees patients, the physician is taught to assess a chief complaint and address it therapeutically. If preventive counseling comes into the picture, it does so as an aftermath to the diagnosis and treatment of pathology or as a didactic lecture appended to a periodic health examination. Neither their formal education, with its hard science focus, nor their entrepreneurial position, which places a premium on technology and treatment, motivates physicians to educate or lead in the movement to prevent disease and injury. The study of health behavior is the province of the social scientist, not the medical scientist. Yet, their very position as the authorities on disease endows physicians with the power to influence health behavior, and their contacts with patients provide them with the means to exercise such power and to study how to do so. Considering the enormous expenditure of effort and money devoted to ways in which physicians can diagnose and treat disease and repair injury, it seems extraordinary that so little attention has been paid to the techniques and pathways which physicians can use to apply the knowledge about prevention which has become available in recent years. There has always been a core of zealots who follow the modern precepts of Doctors “Quiet,” “Merry-man,” and “Dyet.” The problem is how to reach the ordinary man and woman through the day-to-day practice of the ordinary (primary care) physician (10). I do not believe exhortation will produce results. For change in medical practice to occur, solid research must show exactly how the primary care physician can apply current knowledge and must demonstrate that results can be achieved by the practice modifications entailed. The type of research needed is not biomedical or clinical, but collaborative, with a strong dose of social science. There is very little of this type of health services research, and virtually all of it is based in academic practice settings rather than in the office of the primary care physician. The benefits of medical practice over and beyond its surgical and placebo effects are less than a century old. Application of these benefits, the “science” of medicine, is relatively straightforward and compatible with traditional modes of medical practice. What is left, the major part of primary care practice, is often termed the “art” of medicine, a term that seems to relegate it to the realm of mysticism. Yet, it is only by applying scientific principles to this “art” that pre-
326
ventive medicine can win a respected place in the medical curriculum and secure a firm base in the day-to-day practice of medicine. This is precisely the type of research the current administration has ignored (4). What is involved is how to communicate and influence patients who present with destructive behaviors which fulfill some inner need, or with behaviors whose benefits they perceive as outweighing the resultant health costs, or with asymptomatic conditions that place them at risk but are unrelated to the chief complaint or reason for visit. Quite apart from financial incentives, neither the structure and routines of the usual primary care practice nor the expectations of patients are compatible with such an approach to patient encounters. It may not always be reasonable to expect primary care physicians themselves to do all that proves necessary to change behaviors. Collaboration with specialists may be needed just as in the case of complex and rare diseases, although, in this case, the specialists may not be physicians. The role of the primary care physician in such cases-a key role on which all else depends-then becomes one of convincing the patient that consultation and referral are necessary. We have a long way to go to demonstrate the success of such approaches, but the time may be ripe for a start. Only the future can tell us if the current enthusiasm for prevention is truly a cultural condition or is only a screen of rhetoric that prevents us from facing more basic problems of the civilization of our time. REFERENCES 1. Field, M. G. Soviet health, politics and economics. Amer. J. Pub. Health 72, 425-427 (1982). 2. Frank, J. P. in “A System of Complete Medical Police” (E. Lensky, Ed.), p. 290. Johns Hopkins Press, Baltimore, 1976. 3. Glymour, C., and Stalker, D. Engineers, cranks, physicians, magicians. New Engl. J. Med. 308, 960-964 (1983). 4. Norman, C. The Reagan budget: More of the same. Science 223, 564-565 (1984). 5. Pomerleau, 0. F., (Ed.) Introduction to the Proceedings of The University of Connecticut Symposium on Employee Health and Fitness. Prev. Med. 12, 598-599 (1983). 6. Rodale, R. The Rodale Press program. Prev. Med. 12, 663-666 (1983). 7. Rosen, G. “Preventive Medicine in the United States, 1900-1975. Trends and Interpretations.” Science History Publications, New York, 1975. 8. The School of Salemum. Regimen Sanitas Salemitanum. English version by Sir John Harrington (1607), in Sigerist H. E. “Medicine and Human Welfare,” p. 74. McGrath, College Park, Md. 1970 (reprinted). 9. Sigerist, H. E. “On the History of Medicine,” p. 24. MD Publications, New York, 1960. 10. Yankauer, A. Public and private prevention. Amer. J. Pub. Health, 73, 1032- 1033 (1983).
ALFRED
YANKAUER
Department of Family and Community Medicine and Pediatrics University of Massachusetts Medical School 5.5 Lake Avenue North Worcester. Massachusetts 01605
MEDICINE
13, 323-326 (1984)
GUEST EDITORIAL Prevention
and the Public Health
Prevention is a growth industry in the United States. It is not yet a major industry, but it is respectable enough to be embraced enthusiastically by government, hospitals, business firms, commercial publishers, and segments of the medical profession. Recently, the proceedings of a major symposium involving the corporate world were published in an issue of this journal (5). In the words of one of the conference participants: “Since upper management does not have to be convinced that health and fitness programs are cost-effective, research attention can be directed primarily at inventing new programs rather than proving the worth of old ones” (2). This statement is reminiscent of the ebullient optimism that characterized the turn of the century and spilled over into an unquestioning faith in the value of annual medical examinations as a preventive measure for all ages-now obsolete. Two centuries ago, Johann Peter Frank, in his monumental treatise on the social relations of health and disease, distinguished between two types of preventive medicine, the public (action by the state itself) and the private (action by the physician in his contact with patients) (2). In the real world, the distinction is not always that simple. The programs described in the Connecticut symposium reflect a combination of both approaches. Their focus is on the behavior of the individual, but they are offered by employer to employee with inducements to participate, reflecting group, if not government, approval and pressures. The enormous investment in the London drainage system of 1865 and the aqueducts constructed by Roman engineers are clearer examples of what Frank called “public prevention.” Examples of private prevention can also be drawn from antiquity. One of those most relevant to current efforts is the advice offered by the medical school of Salerno to the King of England in the Middle Ages: The Salerne Schoole doth by these lines impart All health to England’s king and doth advise From care his head to keepe, from wrath his heart, Drink not much wine, sup light, and soone arise Use three physicians still; first Doctor Quiet, . Next Doctor Merry-man, and Doctor Dyet. (8)
Although we have greater knowledge about the causes of disease now, and the specifics of our advice may differ somewhat, our general formula for private prevention (health behavior) has not changed appreciably. The modern public prevention movement (or modern public health) was born in the 19th century. Like the advice given to the King of England, the actions taken were sound, but the reasoning that led to them was unsound. The movement itself was given impetus by the growth of the market economy, the demand for 323 0091-7435/84$3.00 Copyright All rights
8 1984 by Academic Press, Inc. of reproduction in any form reserved.
324
ALFRED
YANKAUER
a healthy labor force, urbanization, and the compelling need to regulate living and working conditions in order to control disease epidemics and to make human life tolerable. It is fortunate that the ecologic fallacy that identified atmospheric miasmas as the cause of disease pointed its finger at sanitary conditions as the source of these miasmas. Like all measures to promote health and prevent disease, the 19th century sanitary reforms were “an aspect of the general civilization of the time and largely determined by the cultural conditions of that time” (9). Much hyperbole and occasional fraud taints some of the current private prevention craze (3). The basis for some of the practices proposed are as unproven as were the bases for the private and public prevention movements of the past; nevertheless, I accept the conventional wisdom: “Although proper living and working conditions will not necessarily prevent all disease, there is no doubt that good housing, proper nutrition, absence of undue emotional stress, suitable working conditions, provision of mental stimulation and physical recreation are more likely to produce a healthy people than poverty, malnutrition, ignorance, decrepit housing and the other social evils associated with ill health” (7). The issue, then, is how to capitalize on current trends. An ounce of prevention may be worth a pound of cure, but, as most people see it, a bird in hand is worth two in the bush; the expected effects of preventive measures are in the bush rather than in the hand. Looking first at public prevention, or government action, we are confronted by some striking paradoxes both at home and abroad. Our own government endorses the concept of prevention with its rhetoric and approves of enforcing state laws which, with great success, have required school children to be immunized against communicable diseases; yet the same government refuses to act against far more dangerous agents of disease and injury, such as cigarettes, handguns, and hazards associated with pollution, occupation, and automobiles. There is some indication, via opinion polls, that there is enough of a consensus in the United States for the government to take stronger action against occupational hazards, air and cigarette smoke pollution, and traffic fatalities, as well as the buildup of nuclear armaments. Failure of the current administration to do so is consistent with its general pro-business, anti-regulation policies: Those laws requiring school children to be immunized do not tread on the toes of commercial interests. Our failure to act here, in the United States, does not seem to be related to our form of government or system of medical care, however. The United Kingdom, whose health system we regard as “socialized,” consistently has refused to pass laws requiring immunization and, as a result, is subject to frequent outbreaks of childhood communicable diseases. In the Soviet Union, whose government we consider an enemy of human freedom, citizens are freely allowed to smoke, drink, and eat themselves to death (1). The People’s Republic of China has stamped out prostitution, alcoholism, and narcotic addiction with the iron hand of the state, but does even less than the United States to discourage cigarette smoking and air pollution, although it has full control of all industries, including the production and distribution of tobacco. These paradoxes suggest that group consensus must be reached before laws
GUEST
EDITORIAL
325
that regulate health behavior and health hazards will be adopted under any form of government. Johann Peter Frank’s prescriptions for almost all aspects of daily living were never implemented, even in his native Prussia, under the most authoritarian of regimes. This is not to say that change in health behavior does not occur, only that it is slow and erratic in its occurrence. The promotion of private prevention can speed the pace of such change. This is a role which Frank himself pointed out quite clearly, and remains an important role for physicians to play today. The prevention-promoting role of the physician can be played in three dimensions: as a doctor who sees patients, as a leader-educator who influences public opinion, and as a scientist who studies the human phenomenon. Unfortunately, the present-day physician is unfit by virtue of his education and place in the social system to play any of these roles adequately. As a doctor who sees patients, the physician is taught to assess a chief complaint and address it therapeutically. If preventive counseling comes into the picture, it does so as an aftermath to the diagnosis and treatment of pathology or as a didactic lecture appended to a periodic health examination. Neither their formal education, with its hard science focus, nor their entrepreneurial position, which places a premium on technology and treatment, motivates physicians to educate or lead in the movement to prevent disease and injury. The study of health behavior is the province of the social scientist, not the medical scientist. Yet, their very position as the authorities on disease endows physicians with the power to influence health behavior, and their contacts with patients provide them with the means to exercise such power and to study how to do so. Considering the enormous expenditure of effort and money devoted to ways in which physicians can diagnose and treat disease and repair injury, it seems extraordinary that so little attention has been paid to the techniques and pathways which physicians can use to apply the knowledge about prevention which has become available in recent years. There has always been a core of zealots who follow the modern precepts of Doctors “Quiet,” “Merry-man,” and “Dyet.” The problem is how to reach the ordinary man and woman through the day-to-day practice of the ordinary (primary care) physician (10). I do not believe exhortation will produce results. For change in medical practice to occur, solid research must show exactly how the primary care physician can apply current knowledge and must demonstrate that results can be achieved by the practice modifications entailed. The type of research needed is not biomedical or clinical, but collaborative, with a strong dose of social science. There is very little of this type of health services research, and virtually all of it is based in academic practice settings rather than in the office of the primary care physician. The benefits of medical practice over and beyond its surgical and placebo effects are less than a century old. Application of these benefits, the “science” of medicine, is relatively straightforward and compatible with traditional modes of medical practice. What is left, the major part of primary care practice, is often termed the “art” of medicine, a term that seems to relegate it to the realm of mysticism. Yet, it is only by applying scientific principles to this “art” that pre-
326
ventive medicine can win a respected place in the medical curriculum and secure a firm base in the day-to-day practice of medicine. This is precisely the type of research the current administration has ignored (4). What is involved is how to communicate and influence patients who present with destructive behaviors which fulfill some inner need, or with behaviors whose benefits they perceive as outweighing the resultant health costs, or with asymptomatic conditions that place them at risk but are unrelated to the chief complaint or reason for visit. Quite apart from financial incentives, neither the structure and routines of the usual primary care practice nor the expectations of patients are compatible with such an approach to patient encounters. It may not always be reasonable to expect primary care physicians themselves to do all that proves necessary to change behaviors. Collaboration with specialists may be needed just as in the case of complex and rare diseases, although, in this case, the specialists may not be physicians. The role of the primary care physician in such cases-a key role on which all else depends-then becomes one of convincing the patient that consultation and referral are necessary. We have a long way to go to demonstrate the success of such approaches, but the time may be ripe for a start. Only the future can tell us if the current enthusiasm for prevention is truly a cultural condition or is only a screen of rhetoric that prevents us from facing more basic problems of the civilization of our time. REFERENCES 1. Field, M. G. Soviet health, politics and economics. Amer. J. Pub. Health 72, 425-427 (1982). 2. Frank, J. P. in “A System of Complete Medical Police” (E. Lensky, Ed.), p. 290. Johns Hopkins Press, Baltimore, 1976. 3. Glymour, C., and Stalker, D. Engineers, cranks, physicians, magicians. New Engl. J. Med. 308, 960-964 (1983). 4. Norman, C. The Reagan budget: More of the same. Science 223, 564-565 (1984). 5. Pomerleau, 0. F., (Ed.) Introduction to the Proceedings of The University of Connecticut Symposium on Employee Health and Fitness. Prev. Med. 12, 598-599 (1983). 6. Rodale, R. The Rodale Press program. Prev. Med. 12, 663-666 (1983). 7. Rosen, G. “Preventive Medicine in the United States, 1900-1975. Trends and Interpretations.” Science History Publications, New York, 1975. 8. The School of Salemum. Regimen Sanitas Salemitanum. English version by Sir John Harrington (1607), in Sigerist H. E. “Medicine and Human Welfare,” p. 74. McGrath, College Park, Md. 1970 (reprinted). 9. Sigerist, H. E. “On the History of Medicine,” p. 24. MD Publications, New York, 1960. 10. Yankauer, A. Public and private prevention. Amer. J. Pub. Health, 73, 1032- 1033 (1983).
ALFRED
YANKAUER
Department of Family and Community Medicine and Pediatrics University of Massachusetts Medical School 5.5 Lake Avenue North Worcester. Massachusetts 01605