Prevention: The Big Picture Georges C. Benjamin, MD, FACP, FACEP (E) Executive Director American Public Health Association

As someone who has spent his career promoting public health, it has been heartening to hear prevention discussed as a component of the national health reform dialogue. From the President and members of Congress to doctors, nurses and other health workers in the field, there is a general understanding that prevention is an essential component of an effective health system. This, in itself, is a considerable step forward from when America`s Health RankingsTM was first published 20 years ago.

The inclusion of prevention in a discussion of our nation`s health system stands as a departure from the status quo. Although there is a wealth of evidence supporting the value of prevention as both a way to save money and save lives, the overwhelming majority of every health dollar goes toward treating illness, leaving very little to work with to prevent those illnesses from occurring. This disproportionate allocation of resources is particularly shortsighted when one considers that the leading causes of death and disability in the United States are chronic diseases-like heart disease, cancer and diabetes-that are largely preventable.

According to the Centers for Disease Control and Prevention (CDC), chronic diseases account for 70 percent of the deaths in the United States each year and cause major limitations in activity for more than one of every 10 Americans. Because the causes of chronic disease are rooted in behavior, by their nature they can be prevented through interventions that encourage healthy behaviors, such as being physically active and eating healthy foods. Consequently, prevention stands as an essential element of any effective approach to improving health in our nation.

For all these reasons and more, having prevention included as an important part of the solution to our failing health system is a huge step forward. However, despite this progress, the prevention perspective under discussion remains far too narrow. We need to take several steps back in the process and look at a much broader range of prevention strategies.

The limitation of the current health reform dialogue is that what is primarily being discussed is clinical preventive health services. This level of prevention refers to the screening tests, immunizations, counseling and other strategies that save countless lives each year through early identification of disease. Ensuring their inclusion and accessibility in all insurance policies is an essential element of health system reform. However, rather than identifying a health issue once it already is present, an even more effective strategy would be to prevent the disease from occurring at all. Primary prevention strategies that occur well before a person is in their doctor`s office save money, improve health and can minimize the need for a person to seek medical treatment.

Thus, when we say prevention, we should think of a big-picture, holistic strategy that promotes health and wellness at various levels, from the individual to the community to the health care system. For example, if screening people for high cholesterol is a part of our clinical strategy to prevent heart disease, we ought to be looking back even further to help individuals adopt the healthy eating behaviors that will prevent high cholesterol from ever developing.

Before there is a need for clinical intervention, our first line of defense against disease, illness and disability is primary prevention. These are population-based preventive health interventions that are effective at promoting health and preventing disease. They are a major component of our health care system that works, but whose value is often unrecognized. The leading causes of premature death in our nation can be prevented or reduced through population-based measures that encourage healthy behaviors-like eating healthy and being physically active and tobacco-free. When promoted on a population basis, these measures are cost-efficient and scientifically effective ways to improve health in our nation.

Tobacco, which is discussed in this report as the largest health battle of the last 20 years, serves as a good example to make the case for an emphasis on population-based prevention. Tobacco-related illnesses, which cost our nation more than $96 billion per year in medical expenditures and another $97 billion per year in lost productivity, have been a leading cause of death for many years and much effort has gone into fighting them. We have improved our clinical screening methods and have likely saved countless lives because cancer was detected earlier and treatment was able to begin sooner. We have also saved lives through clinical counseling to help people quit smoking. However, despite these significant clinical successes, the bigger prevention victories have occurred as a result of population-based preventive strategies.

States around the nation have implemented population-based prevention efforts centered around establishing smoke-free policies, changing social norms, encouraging tobacco users to quit and preventing the initiation of tobacco use. Each of these strategies has played a role in reducing the numbers of death and disability associated with smoking. Each person who didn`t start smoking or was able to quit before it was too late is one more life saved and one more person who saves our nation money because they don`t need to be treated for illness. It is in this manner that population-based prevention saves both lives and money.

Another example that highlights the importance of population-based prevention is obesity, which is taking over the role of tobacco and looks to be one of the most critical health battles of the next 20 years. Were we to follow the current approach to health in our nation, we would continue to spend millions treating type 2 diabetes, cardiovascular disease and the other health problems that result from obesity. However, we would be better served by looking to the root of the problem and seeking strategies to prevent people from becoming overweight or obese in the first place. Community prevention initiatives, which focus on teaching kids how to eat healthy, building greenways to encourage physical activity and changing policies to support making healthy choices, are just a few of the population strategies that have proven successful. If we direct our resources towards addressing obesity before it starts, we will see better outcomes, save lives and cut costs.

Beyond the importance of primary prevention as part of a holistic approach to health in our nation, the fact that population-based preventive strategies have often been overlooked in the current health reform debate has policy implications as well. Clinical prevention saves many lives and is widely agreed upon as an essential component of our health system. However, by nature of being a `clinical` strategy, it doubtlessly incurs an associated cost. Thus, as health advocates strive to make the case for prevention as an overarching health reform strategy, clinical prevention is the element that has been scrutinized and has been the target of questions over whether or not prevention saves money.

This limited concept of prevention has permeated the health reform debate and overlooks the element of prevention where cost-savings are easily grasped. Population-based preventive strategies are an effective approach because costs are spread over a large population and non-medical intervention is almost always less expensive. Along with the many states and local communities around the nation that could account for population-level interventions lowering health care costs in their communities, the cost-saving nature of prevention is evidenced by the fact that insurers have recognized its benefits and begun to offer discounts for people who quit smoking, start exercising and take other steps to adopt healthy behaviors.

That said, we must also acknowledge that the cost-savings from prevention is not always something we can see in the short term. If a population-based program prevents a cohort of adolescents from smoking, we won`t reap the cost-saving benefits until they age and aren`t relying on medical treatment for their lung cancer, heart disease, infertility or other health problems.

As we continue to look for ways to improve our health system and lower costs, true health reform must be based around prevention. Health is much more than treating illness and it is time our nation moved away from a sick care system to one that promotes health and wellness. Our clinical care system has an important role to play in reducing preventable death, but it alone is not enough. We must look at the broader spectrum of prevention strategies and invest resources in helping people live healthy lives with a reduced need for medical care. By focusing on helping people stay healthy through prevention rather than simply treating them once they become ill, our nation has the potential to drastically reduce health care costs and save countless lives.

America`s Health RankingsTM was designed to measure and report to the nation the status of our health so that we are able to promote improvements over time. Join me in calling upon our leaders to invest in comprehensive prevention strategies, a cost-effective tool that works.