Last February, the New England Journal of Medicine ran a potentially misleading review of the cost-effectiveness of illness prevention strategies that may have led many casual readers (such as the editors of the Washington Post Health section) to conclude that most health-improving measures — such as aggressive counseling for people who are either overweight or smoke — cost more in the long run than they are worth. This week’s Journal of the American Medical Association carried a proper antidote by Steven H. Woolf of Virginia Commonwealth University, who is fast becoming a leading expert on prevention techniques for improving the nation’s health.
Woolf admits that personal behavior is difficult to change, and many intervention strategies for preventing disease cost more money for the health care system than they save. But he takes direct aim at the NEJM article claim that "drew similarities between the cost-effectiveness ratios of prevention and disease treatments, all but ignoring the much lower cost-effectiveness ratios of the preventive services that guidelines advocate."
But touting those physician-delivered prevention services that are
cost-effective is not the core of his argument. The health care system
is the improper vehicle for delivering the most cost-effective
preventive services and strategies, he argues. "Behavior change occurs
where people live — at home, work and school — but the community
offers little infrastructure for modifying lifestyle."
Advertising, school lunches, restaurant menus, entertainment media,
convenience technologies, and the built environment discourage physical
activity and promote consumption of calorie-dense foods, large
portions, tobacco, and alcohol. Social conditions (eg, inadequate
education, impoverished communities) impose additional barriers.
Boosting prevention is only partially a question of how our society
allocates its health care system resources. A properly defined
prevention campaign requires tackling issues that lay beyond the health
care system. Imagine calorie counts on every fast-food and chain
restaurant menu. Imagine rejuvenated big city public health departments
sending skilled nutritionists bearing dietary advice and training into
low-income neighborhoods suffering from some of the nation’s highest
Giving people the tools to help themselves lose weight is the first
step in the process of reversing the nation’s obesity epidemic. (A new
study, also published in today’s JAMA, showed the rate of childhood
obesity has finally stopped growing, but about a third of all kids are
still either obese or overweight, about triple what it was in the 1960s
Woolf’s hope is that the demonstrable effect that deteriorating
health is having on longevity and the economy will generate the
political will to act. "Self-interest (living longer and healthier) and
common interest (economic stability) may inspire the personal sacrifice
of getting healthy and the collective sacrifice (by the private sector
and the state) of mobilizing the resources to make it happen," he
Merrill Goozner spent more than 25 years in the news business as a
foreign correspondent, economics writer and investigative reporter. In December 2003, he joined the Center for Science in the Public
Interest as director of the Integrity in Science project, where he
continues his research and writing. He blogs regularly at gooznews.