The emphasis on prevention

Abstract

J . he role of physicians, dentists, and other health practitioners in prevention as well as treatment has often been overemphasized. It is true that the physi­ cian has a role to play, especially in the early detec­ tion of disease, and that physicians may have a pro­ nounced effect on the compliance of their patients with therapeutic regimens. And it is true that pre­ ventive measures in dentistry, such as dietary fluoride supplementation, have also proved effec­ tive. But the greatest accomplishments in preven­ tion have been either public health measures or in­ dividual initiatives in health habits and life-style. The most effective means of disease prevention and improved health status lie outside the medical care process and are related to reducing hazards in the environment, improving nutrition, and adopting appropriate personal habits. The conventional view that physicians must do more, or that we must have more of them, certainly misses much of the problem that faces us. The rela­ tively poor health of millions of Americans is related to inappropriate life-styles. This fact does not, of course, absolve society and the health care profes­ sions of responsibility for the consequences of such life-styles. As one observer has said, blaming the victim “ignores what is known about human behav­ ior and minimizes the importance of evidence about the environmental assault on health.” Individuals must be guaranteed a considerable amount of freedom to live as they please. Neverthe­ less, that freedom is subject to constraints. Freedom for one set of behaviors must be weighed against the rights of others to substantially different life-styles. For example, persons who smoke in crowded public places infringe on the rights of nonsmokers. Moreover, if individuals choose to engage in behav­ iors that lower their health status, even those who do not behave in that fashion must still help to bear the cost. In addition, all of us are limited in our ability to control our health environment. Those who live and work in cities, for instance, have limited ability to accept or reject the various environmental pollu­ tants. The responsibility for the prevention of disease and disability through health education, improved life-style, and environmental control permeates all aspects of society— the individual, the family, the school, the workplace, voluntary agencies, and every level of government. We believe we can ele­ vate our collective sensibility to that responsibility without further medicalization of our society. In seeking a major change in societal values and attitudes toward health, the trade-off appears to be between these values and individual freedoms. Societal values and attitudes toward health are not necessarily perceived as relevant to individuals, but the freedoms are individually indulged. Yet unless we continue to expand our efforts to relate societally and individually induced risks to specific health outcomes, as a nation we will— at best— do better and feel worse. If we, as a society, can improve our health status without expecting to do this by investing in the medical care system, if we begin refusing to promise more than we can deliver, and if we can more equi­ tably distribute the responsibility for preventive medicine among the public health sector, corpora­ tions, and individuals, we may be able to direct our considerable energies to appropriate ends.