An Ounce of Prevention Not Worth a Pound of Cure?

The U.S. historical figure Benjamin Franklin (1706-1790) is credited with a body of aphorisms or sage sayings.  I don't know if he was a collector or whether he was an inherently astute and wise person, and was able to harvest these sayings from his own intellect and experience.  Perhaps it was both.  In any case, one of the most widely quoted is in the title, comparing the value of prevention versus cure.  It is conventional wisdom that this is true.  Like most things health-related, concepts are more complex.  While in most circumstances, it is better to prevent than cure, the general principle must be qualified.

In the federal government health bureaucracy there is a  unit called Agency for Healthcare Research and Quality.  The title is revealing of the general mission of the organization; it is most meaningful for health professionals and health promotion workers, but there is some material provided for interested consumers as well.  One of the agency's specific functions is carried out by the  U.S. Preventive Services Task Force.  This group of 16 experts, with credentials in prevention, evidence-based medicine and primary care, was first established in 1984, to provide a systematic way to guide prevention service in primary health care.  Using sytematic reviews of the published medical and health promotion literature, the Task Force outlines evidence for a long list of preventive services sorted into three types: screening, patient counseling, prophylactic use of medications.

Based on all available evidence, the Task Force will assign grades A(strongly recommended) through D(not recommended) and I for insufficient evidence.  So for example, prostate cancer screening for men over 74 gets a D, not recommended.  For men between the ages of 45 and 79, taking a daily aspirin to prevent myocardial infarction (heart attack) gets an A, strongly recommended.  Using ultrasound in the second trimester to improve pregnancy outcomes gets an I, for insufficient evidence.

The following widget will bring you to a list of screening services that might have some applicability to readers.  Just fill in the basic details and submit.  This will show the  grading of each screening service, with explanations for the basis of the grading.



This effort, and ones like it, have been dragged into the political process, and cited as examples of government bureaucrats getting in between you and your doctor.  That is an unfair charge.  First of all, bureaucrat is a term that doesn't mean anything useful.  It is a throwaway term, not one that communicates anything precise.  As outlined above, the members of the Task Force are highly trained professionals.  Most of them do not work for government.  Their work is science driven, and they are accountable for their decisions regarding the services they review; the basis of their grading has to be explained and defensible.  Finally, by and large, the recommendations are guidelines, which are in fact widely ignored.  For example, most men are given the PSA prostate cancer screening test, even though it is not recommended by the Task Force.  The point is to help the system use resources in a way that will maximize health outcomes and minimize untoward consequences and side effects.  In a system as large as ours, it is unrealistic to think that getting all primary care physicians and nurse practitioners to know and comply with the recommendations will be easy or quick.  It is an effort in the right direction.

Some of the recommendations have led to system changes through insurance mechanisms.  For example, routine colonoscopy is not recommended for people under the age of 50.  A person under 50 could self-pay and get a colonoscopy, but many insurance companies will not pay for the procedure.  On the other hand, 2nd trimester ultrasound has become standard practice, supported by insurance, but the Task Force has not found enough evidence to support it.  Rome was not built in a day......

This issue has broad relevance to health promotion, even though these services are primarily delivered by clinical care providers.  There is an education and communication process that must be part of any effort to promote adoptation of any specific preventive service and compliance with the recommendations as a whole.

Ben Franklin did not realize how compicated prevention and cure would become, 200 years later.