In an interesting “Special Communication” in the July 3, 2013, issue of JAMA, Harvey Feinberg, MD, Ph.D., President of the Institute of Medicine takes a stab at examining why we are so resistant to doing what we know we should.
Here are his top 12 reasons why prevention is difficult:
1. Success is Invisible
It is almost impossible to prove causality. Did my daily exercise prevent me from getting a heart attack? Or was it something else? Conversely, we have all heard the tales of someone crediting their long life to a daily dose of gin. Can the gin really take credit for longevity? Or was it something else?
2. Lack of Drama
The TV show ER was a smashing success in part because of the action. People came into the ER really really sick and (within a half hour), they got cured. That’s cool. But as Dr. Feinberg points out, there will likely never be a TV show about prevention because “think about the plot line: Nothing happens.”
3. Statistical Lives
People relate to personal stories. That is why most healthcare stories in the media include a story about someone affected by the condition or issue being reported. It paints a picture for us, particularly if we identify with the individual in the story. But statistics just don’t grab us in the same way. Twenty-five thousand deaths could be avoided or 100,000 kidneys could be saved is interesting, but not as compelling as Janie Wylie, a 13-year-old girl with leukemia or Bobby Smyth, a 50-year-old on dialysis.
4. Long Delays Before Rewards Appear
Most people want to get their rewards right away. Being told you may avoid a heart attack if you spend decades exercising and eating right just doesn’t cut it.
5. Benefits Often Do Not Accrue to the Payer for Prevention
In fact, organizations or other entities that pay for prevention may actually lose if the preventive efforts are successful. Dr. Feinberg gives the example of a hospital paying for a community-based diabetes program that was so successful fewer diabetics were admitted to the hospital.
We all know the incentives in healthcare are seriously misaligned. Until we fix that, organizations that make money based on sick care are unlikely to make the massive investment that prevention programs may require.
6. Changing or Inconsistent Preventive Advice
We all know that coffee drinking is alternatively praised and damned. The same is true with other nutritional recommendations. Screening tests are another area of confusion for consumers (and clinicians as well). PSA—good or bad? Mammograms under 40—needed or not? If the public isn’t clear on what to do, chances are they will likely do what is easiest for them.
7. Persistent Behavior Change May Be Required
Boy o boy! This one resonates with me. I can do anything for a little while, but being good day after day forever…that is a different story.
8. Bias Against Errors of Commission
Some people will choose to not do something because of potential adverse consequences (e.g, childhood vaccines (false) link to autism), as opposed to doing something that may have a benefit (vaccinated kids won’t get measles or rubella).
9. Acceptance of Avoidable Harm as Normal
Folks may just accept that certain bad things that happen to us are “normal.” Perhaps that is why there is not more outrage about mass shootings or domestic violence. Hey, stuff happens.
10. Double Standard in Evaluation of Prevention as Compared with Treatment
We have institutionalized an expectation that prevention needs to have an ROI. Treatment must work, but prevention must save money. Since the time frames for returns, as discussed above, are often quite delayed, it’s no wonder that prevention programs have to fight for every penny and are often under- (or un-) funded.
11. Commercial Conflicts of Interest
This is a big one. Companies make a lot of money selling us stuff that is bad for us (e.g., cigarettes, high calorie, low nutritional value fast food, rapid-fire, large magazine guns). Prevention programs often directly target their sources of revenue. No wonder they fight so hard to maintain market share—even in the face of evidence of harm to the health of their customers.
12. Conflicts with Personal, Religious, and Cultural Beliefs
It is very difficult to counter religious edicts and culture beliefs (e.g., abstinence instead of condoms, faith healing instead of western medicine). Steve Jobs’ belief that he could treat his pancreatic cancer with diet is an example of how personal beliefs (no matter how magical the thinking) will trump the advice from physicians (and friends).
Only by understanding barriers to prevention can we have a hope of creating and carrying out programs that will really work. Kudos to Dr. Feinberg for a thoughtful essay.