Prevention vs. Treatment: A False Choice

The long-running debate over the relative importance of prevention or treatment is the theme that at least a dozen global health bloggers are exploring today. In many ways, the debate represents a false choice; a well-functioning health system requires both prevention and treatment. But how do you strike the right balance? Is the measuring stick simply the one provided by economics? Or do equity and fairness also play a role?

“An ounce of prevention is worth a pound of cure,” or so the old saying goes. But we don’t always practice what our folk wisdom preaches.

The U.S. medical system, as currently set up, rewards cardiac surgeons at a much greater rate than it does programs for avoiding weight gain or controlling high blood pressure.

About 5% or less of the U.S. budget on health care is spent on prevention, according to Don Wright of the U.S. Department of Health and Human Services. Most of the rest is spent on treatment—and, I would venture to guess, paper work.

And yet, you can bet that if I ever experience a gripping pain in my chest or back, accompanied by nausea and perhaps an overwhelming sense of anxiety—classic signs of a heart attack in women—I am going to get myself to an emergency room right away to get treated and be mighty thankful if the specialists at the cardiac catheterization lab can open up any blocked arteries.

The year I spent at Harvard taught me a lot about how academics argue the prevention vs. treatment debate. Indeed, just a few years ago there was that rare thing in public health—a big public debate between some folks at the Gates Foundation on one side and some at Harvard on the other about whether prevention or treatment was the better—read more “cost-effective”—approach to tackling HIV/AIDS in sub-Saharan Africa. Eventually the Harvard side won the argument—especially once the cost of anti-retroviral therapy dropped dramatically. What made the difference was the fairness issue: How could you withhold treatment when so many were dying?

A few months in rural Malawi gave me a whole other perspective. There I learned that tremendous strides have been made in decreasing maternal death rates at the Embangweni Mission Hospital through a variety of efforts—not least of which was an emphasis on both prevention and treatment.

It did not happen by accident and it did not happen overnight. When the effort began, several years ago, there was only a single sink in the labor and delivery room. So improving the physical plant was a priority in terms of providing better treatment. Embangweni Hospital also worked really hard to get the right people in the ward—namely more nurses and clinical officers—and keep up their training. Alas, hard experience also taught them they had to make the ward off-limits to many of the grandmothers or “gogos,” who would slip their daughters and daughters-in-law a powerful herbal concoction to induce labor but that also increased the risk of potentially fatal uterine rupture.

On the prevention side, community health nurses have been working throughout the South Mzimbe region for the past ten years to provide prenatal care to pregnant women. To give just one example, the community health workers I met, like Joyce Ngoma and Tamala Chirwa, work hard to identify women who may have trouble delivering—because they are carrying twins or the fetus is not positioned properly. The nurses advise those women to go to the hospital early so that they can be watched more closely and scheduled for a caesarean operation, if need be.

Each side—prevention and treatment—benefits from the other. With fewer pregnant women showing up at the hospital in crisis, the clinical officers and nurses there are able to save more mothers' lives. The nurses in the field can see that their efforts have saved lives and are encouraged to do more prevention work.

Today's posts on Prevention vs. Treatment from other global health blogs (as I learn of them):

Healthtwine: Prevention vs. Treatment
On why "we tend to value current health more than future health."

Superbug: Prevention v. treatment (1st Global Health Blog Carnival!)
On the need for a vaccine against methicillin resistant staph aureus.

Perspectives: Prevention vs. Treatment
On why prevention vs. treatment is the wrong way to think about drug resistance to malaria.

Karen Grepin's Blog: Prevention vs. Treament in HIV: Have we given prevention a chance to shine?
Proving prevention works is a lot harder than you might think. Maybe that is another reason why there are so few studies on the effectiveness of prevention.

The Pump Handle: For Whom Prevention Pays
On one of the bigger, overlooked stories of public health in the U.S.--the faltering anti-tobacco struggle, another victim of the economic crisis.

HIV Information for Myanmar: Two Quotes from Bogyoke
A few words on the greater good from the late Bogyoke (General) Aung San, who led the fight for Burmese independence after World War II.

Health Reform Watch: Health Care, "Common Sense" and a Global Health Blogging Experiment
A bit off-topic and somewhat rambling (the French revolution?), but a look at whether concerns over health reform in the U.S. will crowd out discussion of global health.

Global Health at Change.org: Prevention vs. Treatment--an Eternal Debate?
On why good decisions in public health "are about balance, and looking for long-term systemic solutions instead of the quick fix."

And from a public relations perspective:

Ruder Finn's DotOrg (U.K.): The Lazarus Effect
Lucy asks "Are there are any differences between ’selling-in’ stories that have a prevention angle over those that emphasise treatment."