PREVENTION: WHOSE RESPONSIBILITY IS IT?

Prevention has successfully decreased the mortality and morbidity associated with many diseases. The introduction of effective vaccination programs, for instance, has significantly reduced the impact of a number of infectious diseases, such as diphtheria, tetanus, poliomyelitis, rubella, pertussis, pneumonia, and influenza. Screening of newborns for metabolic diseases such as hypothyroidism and phenylketonuria has reduced the impact of these diseases on the children's cognitive functions. Similarly, the early detection of hypertension and hypercholesterolemia has reduced the age-adjusted mortality from strokes by more than 50% over the past 30 years. The implementation of screening programs to detect cervical neoplasia also has dramatically reduced the incidence of invasive cervical cancer.

Regrettably, however, preventive medicine still does not occupy the prominent place it should. The general public appears to be apathetic toward prevention, especially when it involves a change in life-style, is expensive, or necessitates invasive tests. Clinicians, too, are unable to devote enough time to prevention because most of the time they are dealing with acute clinical conditions or exacerbations of chronic diseases. Seldom does a patient consult a physician solely for the purpose of prevention. The fragmentation of health care delivery and the inadequate reimbursement for preventive services also are major barriers to the implementation of effective preventive services.

Regrettably, too, clinicians are often still uncertain as to which preventive services should be offered, when they should be offered, and when they should be repeated. Although a number of guidelines are available, most are developed by specialized organizations with their specialty in mind, and clinicians may be overwhelmed at the sheer volume of preventive services that could be offered. To complicate matters even more, recommendations by various organizations or agencies may differ. This may be a reason for skepticism and lack of enthusiasm among clinicians about the effectiveness of various preventive services.

The US Task Force on Preventive Services addressed this last issue and resolved many of the uncertainties concerning the effectiveness of selective preventive services. The Task Force carefully reviewed the evidence supporting the use of several preventive services and published its findings in the Guide to Clinical Preventive Services (Second Edition, Baltimore, Williams & Wilkins Co, 1996). Its main general conclusions emphasize the following: (1) the need for clinicians and patients to share decision-making concerning preventive services; (2) the need for clinicians to be selective in ordering tests and providing preventive services; (3) the need for clinicians to take every opportunity to deliver preventive services, especially to those with limited access to care; and (4) the fact that community-level interventions may be more effective than clinical services for some health problems. The Task Force also emphasized the importance of interventions addressing each patient's personal health practices.

It is indeed sobering to realize that approximately half of all deaths occurring in the US may be attributed to external factors such as cigarette smoking, illicit drug use, and risky behaviors such as not wearing safety seat belts, driving while intoxicated, and high-risk sexual practices. It is in many ways enlightening that so many people engage in these high-risk activities knowing the risks involved and yet thinking that nothing untoward is likely to happen to them. Physical inactivity and dietary factors contribute to atherosclerosis, coronary heart disease, diabetes mellitus, osteoporosis, and

many other diseases. And yet, being overweight is rampant and high calorie, high cholesterol, low fiber, fast food is available virtually everywhere and anytime in the US. There obviously is a great need for public education. Individuals must assume responsibility for their life-styles.

The practice of medicine has evolved considerably over the past few centuries, but especially so over the past few decades. Paternalistic practices are no longer acceptable. Patients want to be informed about their diseases, the tests ordered, and about their diagnosis and prognosis. Many patients spend hours on the Internet collecting data about their medical condition. Patients demand to be fully informed and want to be part of the decision-making process. By the same token, however, patients should assume responsibility for their own health care and especially for taking the necessary precautions. They should avoid risky behaviors and should take positive steps toward achieving and maintaining their maximum health potential.

Ronald C. Hamdy, MD, FRCP, FACP 

Editor