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Is prevention better than cure?

Is Prevention Better than Cure?

By Louise B. Russell. Washington, The Brookings Institution, 1986. 134 pp. $26.95, cloth; $9.95, paper.

Recent years have seen increased efforts to slow the growth in the Nation's expenditures on health care--growth that has doubled the share of the gross national product spent on health care from 5.3 percent in 1960 to 10.7 percent in 1985. One major approach has been to make consumers of health care more cost-conscious, by having them (rather than insurance companies, for example) pay a larger share of the cost of medical care. In this trim, compact volume, Louise B. Russell focuses on another approach that has received wide endorsement as a means of slowing the growth of the Nation's medical-care bill: prevention.

The bulk of the book consists of a review, evaluation, and synthesis of the evidence of the cost-effectiveness of several preventive measures--the smallpox and measles vaccines, screening and drug therapy for high blood pressure, and exercise. Russell shows that, for a variety of reasons, the common impression that prevention of an acute condition is cheaper than the cure of the condition is not necessarily correct. First of all, the size of the population at whom prevention is directed may be very large compared to the incidence of the illness in the absence of prevention. Such a situation developed in the United States, for example, with respect to smallpox vaccination, and, for that reason, this country officially ended its policy of routinely vaccinating children against smallpox.

In addition, one must consider how often the preventive measure must be conducted. Repetition of the procedure is necessary, for example, in a program of screening for high blood pressure as a way of reducing incidence of heart disease and stroke. Russell points out that not only does one's blood pressure fluctuate during the day, but--because of the anxiety involved--one's pressure is usually higher on an initial reading than on later readings. As a result, "a third to a half of the people with high pressures at the first exam are likely to have pressures in the normal range at the second or third exam' (p. 66). The author explains that for several additional reasons--including the side-effects of blood-pressure medicine--claims for the cost-effectiveness of preventing heart disease through screening and drug therapy should be taken with a grain of salt.

Perhaps the most interesting part of the book is the chapter on exercise as a preventive measure. Russell writes that there has been no systematic evaluation of the cost-effectiveness of exercise as a means of improving health, but she assesses the available evidence on the subject and proposes a framework for conducting a more definitive analysis. The author shows that the full costs of an exercise program are far higher than are initially apparent, because they include the costs of equipment and of a medical exam before one begins to exercise, the value of the participants' time, and the injuries that result from exercise. This discussion and the implication that exercise may not be cost-effective are extremely important because they provide the sedentary among us with an economic justification for our inactivity.

Russell concludes that "even after allowing for savings in treatment, prevention usually adds to medical expenditures, contrary to the popular view that it reduces them' (p. 110). She acknowledges, however, that good health has intrinsic value and is worth paying for.

In a concluding chapter, Russell suggests a standardized framework for future studies of the cost-effectiveness of preventive measures as investments in health. She proposes, for example, that such studies should adopt the perspective of society as a whole; that is, they should consider all the costs and effects of a preventive program, regardless of who experiences them. Russell urges, too, that all such studies use the same discount rate. The choice of the discount rate can obviously have a great effect on the results of the studies, because the benefits of a preventive program do not materialize until long after the costs are incurred. Also, Russell suggests that the additional medical expenses that arise because a person lives longer should not be counted in cost-effectiveness studies, just as the corresponding additional expenditures on food and clothing are not counted.

I believe that this book is a valuable addition to the literature in its field. Read it yourself, though, and get a second opinion.
COPYRIGHT 1987 U.S. Bureau of Labor Statistics
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1987 Gale, Cengage Learning. All rights reserved.

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Author:Steinberg, Edward
Publication:Monthly Labor Review
Article Type:Book Review
Date:May 1, 1987
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