Disease prevention has fallen on hard times. This according to a New York Times article last week titled “What’s a Pound of Prevention Really Worth?”
The article opens with a description of Dr. Arthur Agatston’s practice. Although he is most famous as a diet doctor for writing “The South Beach Diet”, he’s a cardiologist—like Robert Atkins, whose diet also originated with the same concern for preventing heart attacks. In fact, the South Beach Diet bares more than a passing resemblance to the Atkins diet, but that’s another story.
Last year, Dr. Agatston claims only 3 out of his 2,800 patients had heart attacks. He attributes his success to the time and attention he and his staff take with each of his patients to change their diet, exercise, and other aspects of their life (like how to stop smoking). The regimen also includes doses of statins and other drugs, with time and attention devoted to dealing with the side effects.
What’s the problem?
Dr. Agatston summarizes the situation this way: “The time we spend with patients—we get rewarded almost zilch.” He is able to do it because he has the South Beach Diet empire as an independent source of income. Other doctors who are not so blessed avoid preventive care because it doesn’t turn a buck.
And so the article blathers on about what looks like an intractable problem: prevention is good but money can’t be made by the doctors who deliver it. But wait. Why are doctors responsible for prevention in the first place? A piece of the answer is in a series of articles published recently in the Public Library of Science on the topic of Social Medicine.
The strategy that Dr. Agatston uses is intended to change individual behavior, one patient at a time. The strategy of Social Medicine is to change the environment for medical care including prevention. Instead of working one-on-one to induce someone to adapt to a prescribed diet, Social Medicine works to change the patient’s food environment: access, affordability, and so on. Some advocates of Social Medicine go so far as to suggest that a redistribution of income and wealth by itself would improve medical care outcomes. Fancy that.
This socialized approach to medical care is more prevalent in Europe than in the United States because of a stronger tradition of socialized medicine and a strong, independent public health movement. In the United States, public health was first eclipsed and then colonized by the medical profession. Despite an ongoing interest in social medicine by public health researchers and officials, a complex of institutional, political, and financial factors have forced the practice of public health to become an extension of individualized medical care. “Prevention” means vaccination, but not day care. That’s changing, although slowly.
Yet even if, optimistically, Social Medicine were to rise in prominence, it’s still medicine. Prevention is still medicine. It’s about making diagnoses and prescribing treatments—whether individual or collective. What happened to health?
Health is not the absence of disease. Your absence from the doctor’s office is not the same as health. Health, like illness, comes from how your unique biology responds to your environment, both physical and social. Your health is simply your biological capacity to get what you want from life.
Maintaining and improving your health isn’t simply or even mostly about medical care whether for prevention or treatment. As we discussed last week, your health might actually be better served by avoiding medical care. It’s also, even principally about creating environments, both physical and social, in which you and I and people we don’t even know can thrive.