In Cities and the Wealth of Nations, Jane Jacobs tells how, in the 1920s, one of her aunts moved to an isolated North Carolina village to, among other things, have a church built. The aunt suggested to the villagers that the church be built out of the large stones in a nearby river. The villagers scoffed: Impossible. They had not just forgotten how to build with stone, they had forgotten it was possible.
A similar forgetting has taken place among influential Western intellectuals — the people whose words you read every day. Recently I wrote about why health care is so expensive. One reason is that the central principle of our health care is not the meaningless advertising slogan promoted by doctors (“first, do no harm”) but rather the entirely nasty first, let them get sick. Let people get sick. Then we (doctors, etc.) can make money from them. This is actually how the system works.
It is no surprise that doctors and others within the health care system take the first, let them get sick approach. It is wholly in their self-interest. It is how they get paid. If nobody got Disease X, specialists in Disease X would go out of business. What is interesting is that outsiders take the first, let them get sick attitude for granted. It is not at all in their self-interest, just as it was not at all in the self-interest of the Carolina villagers to think building with stones impossible.
An example of an outsider taking first, let them get sick for granted is a recent article in the London Review of Books by John Meeks, an excellent writer (except for this blind spot). The article is about the commercialization of the National Health System. Much of it is about hip replacements. How modern hip replacements were invented. Their inventor, John Charnley. How a hospital that specialized in hip replacements (the Cheshire and Merseyside NHS Treatment Centre) went out of business. And so on. Nothing, not one word, is said about the possibility of prevention. About figuring out why people come to need hip replacements and how they might change their lives so that they don’t. Sure, a surgeon (John Charnley) is unlikely to think or say or do anything about prevention. That’s not his job. But John Meeks, the author of the article, is outside the system. He is perfectly capable of grasping the possibility of prevention and the parasitic nature of a system that ignores it. Long ago, people understood that prevention was possible. As Weston Price documents, for example, isolated Swiss villagers knew they needed small amounts of seafood to stay healthy. But Meeks — and those whom he listens to and reads — have forgotten.
And yet when politicians talk about saving money by spending more on prevention and less on cure, I assume that the “prevention” will be some puritanical doctrine for which no good evidence exists. After all, for decades the buggers told us not to eat egg yolks.
Nor, come to think of it, butter.
i guess you’re right. doctors would never ever tell someone to stop smoking, for example, and more perversely lung cancer rates have been skyrocketing in the USA because neither physicians nor public health officials have any attempt to convince people to stop smoking.
But smoking is the past – the only really substantial mass killer identified successfully by more-or-less modern epidemiology. (And even then it’s worth noting that the original discovery of the perils of smoking was rejected by doctors on the grounds that it was Nazi science.) Since then doctorly lecturing has been regularly based on weak or absent evidence. Or it amounts to a feeble repetition of the stuff your mother told you – “Go out and play, dear” – or, as I say, erroneous countermanding of your mother’s excellent advice to eat up your egg.
Dim-witted nagging is not the same thing as prevention.
Very true, but until that message gets out to the masses, it will be more of the same. My former doctor was convinced I would drop dead very soon because I declined to take a statin. He also said there was no way to correct lipid numbers with diet. Wasn’t even willing to give me some time to see if it would work!
“Doctors would never ever tell someone to stop smoking, for example.”
yeah, “for example”. Except that (a) it is almost the only example and (b) everyone already knows smoking is unhealthy and (c) giving such preventive advice is a very small fraction (0.1%?) of what doctors spend their time on and (d) this advice is 50 years old — that is, stale.
The other example of what a doctor might do to prevent disease I can think of is telling patients to lose weight. As if (a) the patient didn’t realize he/she was fat and (b) the notion that they should lose weight was a new idea.
If you went to a doctor and all they did was tell you to stop smoking and lose weight you might wonder if they were an imposter — if they went to medical school. You would certainly resent paying $100 or whatever for such blindingly-obvious advice.
I think it is difficult to quantify how many illnesses or diseases are directly the result of poor lifestyle or risky behavior.
It is equally difficult to paint the health care industry with the same brush because it is so varied from state to state let alone from nation to nation.
Doctors do not have a vested financial interest in the basic health and safety of people while they are healthy. Car companies have a financial interest in making cars safer to avoid excessive litigation, but doctors are only called in when people require their services. Should doctors be paragons of public health and safety? Should they like priests of old preach to the masses the evils of certain risky behaviors?
Im not so sure, and in Canada there exist layer upon layer of prevention and safety positions staffed by doctors and nurses to preach that same message to the people. The assumption your argument appears to rest up is that sending a message of prevention will be received and put into practice and what line should this message not cross? If these strategies worked, let us compare mortality/accident rates for nations with varying levels of spending on prevention/health and safety type outreach among medical professionals to qualify that sentiment.
Medical professionals are not without their own disagreements and moral dilemmas, asking a doctor to invest himself in prevention could result in varying messages, some smacking of a morality not shared by all and not scientific in nature. This would simply give rise to a sort of propaganda unit of central control to provide the message doctors “ought” to give, which in itself presents a host of problems.
A carpenter should not beyond a moral inclination be expected to learn about sustainable tree planting to work with wood. With the amount of training for a doctor just to treat the sick, we might make best use of their time doing just that. Prevention is a messy tangle of morals and science when we move beyond the very basic messages.
Doctors preach already to patients to stop smoking or loose weight, but many simply refuse to listen because there is little or no incentive to do so. The message is not the problem, human nature is.
The reason doctors make an exception to the “no prevention” rule for smoking and losing weight is simple: they know from experience that almost no one can or does follow that particular advice.
Tabacco chewing was considered a filthy habit at least as long ago as 1870, and I hope you’ll excuse me for concluding that cigarettes would have acquired the moniker instantly, by association.
Especially as it in fact smells bad. Fifty years old is too young by a factor of nearly three.
Seth, I’m a regular reader and really appreciate your blog.
Re your above piece, I have often thought that a better term than disease “prevention” would be to coin the term “disease avoidance.” That’s because it seems the term “prevention” in this context has been corrupted to refer to the marketing and delivery of more and more medical services such as annual physicals and regular medical testing,. The resulting doctor prescriptions of pharmaceuticals for high blood pressure, “high cholestrerol” and “treatment” of numerous other “conditions” are of course intended to be prescribed for the remainder of the patient’s life and need to be constantly monitored by the service provider. More visits, more services, more income for you-know-who.
With regard to the example of prescription of drugs for many of the typically diagnosed “conditions,” it is clear that most of these don’t actually cure any condition in anybody; but they sure pad the income statements of the drug manufacturers year after year. The result is that the system is well on its way to bankrupting Medicare and Medicaid. I’ve also arrived at the view that many of these conditions (especially type 2 diabetes which is now rampant) are almost always the result of a bad nutritional lifestyle, not genetics.
So in the end, the system seeks to market a type of “prevention” that puts money in the pockets of medical care professionals, hospitals and pharma companies, but hardly ever prevents illness and doesn’t cure anybody. I suppose all of this has become the driver of a terribly corrupt and unsustainable “let them get sick” medical system.
BTW, while I’m in rant mode, we should all stop using the misleading term “health care” system since the system has evolved to a point where the “health” of the individual has become largely irrelevant. It’s now just about churning profit.
yes, WCB, that’s a good point. Our health care system is happy to do “prevention” so long as it is expensive — e.g., statins. The quality of this prevention is indicated by the finding that statins don’t seem to help people who haven’t had a heart attack.
A question for Seth. What are the prevention strategies that you think doctors should be sharing with their patients? Bear in mind doctors are going to be hesitant to share health advice without a strong base of evidence.
One possibility for prevention of joint problems– Feldenkrais method is a system of gentle movements done attentively so that people can recover varied, well-coordinated movement.
Jeff, I think doctors are helpless. They can only repeat what they are told. There is a lack of prevention research. That’s where a better health care system would start: with more prevention research.
Nancy, I suspect a lot of hip replacement is due to inflammation, which would be prevented by sufficient omega-3.
@Nancy:
In addition to Seth’s comment (about omega-3 supplementation being helpful in preventing joint problems), I would like to mention the work of Dr. William Davis regarding the problems of inflammation, arthritis, celiac disease (and many other serious issues) caused by consumption of grains, particularly wheat.
In case you aren’t familiar with Dr. Davis, he is a practicing cardiologist in Milwaukee and offers a lot of useful info on his Heart Scan blog. Dr. Davis also recently published his book entitled “Wheat Belly” which is newly listed in the NY Times book review as number 5 on the best seller list for its category.
It looks like Dr. Davis is really onto something when it comes to sound ideas for prevention (or avoidance, as I prefer to think of it) of a number of common diseases, all based on his clinical experience with numerous patients and research he has done on the subject.
WCB
Seth, your critique is right in line with a couple of books I read recently: “Over-Diagnosed” by Dr Gilbert Welch, and “Worried Sick” by Dr Nortin Hadler. Both point out that a great deal of today’s medical practices, especially the purportedly “preventive” stuff, is unproven, and worse is making us sicker. I reviewed the books on my blog (https://bit.ly/opoqAl).
Rajiv, thanks for drawing my attention to Over-Diagnosed. It sounds good.
Also, “Selling Sickness”