Thursday, January 29, 2009

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 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."


Anonymous said...

Christine, thank you for organizing this. I agree with your idea that prevention vs treatment is not really the main issue here; as with all things there is a healthy equilibrium. Naturally, sometimes treatment works better, sometimes prevention.

My question to you is: given that the "fairness" aspect plays an essential role in deciding whether to prevent or to treat, how do we reconcile everyone's different assessment of fairness?

Are we bound to break down into a dichotomous argument, similar to the "discussion" over free markets vs egalitarian values?

I've covered some of the same topics as you in my post. Leave me some of your thoughts!

Maryn McKenna said...

My post is in as well, from the MRSA perspective:

Anonymous said...

This is a really interesting experiment. I have added a PR perspective to the debate. See the link below:

Anonymous said...

Very interesting. I don't think the treatment vs. prevention polarity is the issue, either. But coming from a layperons' position, I view it in terms of public policy and personal experience.
This discussion is a great idea, Christine, and I'm interested in reading how bloggers with different perspectives view the whole subject.

Christine Gorman said...

Thanks, Jimmy, Maryn, Lucy and Larry. We've planted the seed. Now we'll see how it grows.

Karen Grepin said...


Thanks for organizing this. I have linked to your posting from mine:


Anonymous said...

Sorry to be coming late to the carnival -- I've just put up my post on how prevention pays.

- Liz said...

Coming rather late myself, but here nonetheless. I chose to explore the issue of the experiment itself, and the exposure difficulties global health concerns seem destined to face in light of the current clamor for health care reform in the U.S. I use Thomas Paine as a comparison.

Anonymous said...

Yes, more often than not, prevention vs treatment is a false choice. As you suggest, policy makers inadvertently create the conditions where that choice is unavoidable. The pressure to report tangible results to justify expenditures (exacerbated by the Paris Declaration on aid effectiveness) is very often reduced to reporting the distribution of commodities, be they for prevention or treatment. Thus, a strategy may be preferred (and another overlooked) simply because its outputs can be measured and reported more easily. The Global Fund defines success for its AIDS programme in terms of the numbers treated with ARVs, and the success of its malaria programmes in terms of the numbers of nets distributed. It is not so much a choice between prevention and treatment but a choice on the basis of measurability. If this is the case, it may help to explain why more complex interventions for maternal health and child survival – where indicators and outputs are less clearly defined - are so readily overlooked.

Anonymous said...

Thanks so much for putting this together! I've really enjoyed reading all of the posts.

I love your example of the community health nurses who get to see the happy results of their prevention efforts. Maybe making results more visible would be one way to create more support for prevention programs.

- Liz (The Pump Handle)