The Politics of Prevention
The Politics of Prevention
Those of you who read this column routinely can reliably predict my vote, so no need for me to say what it will be. There are reasons, however, directly related to my purview here- preventive medicine– to say why it will be what it will be.
Prevention covers a broad clinical expanse, encompassing disease treatment as well as primary prevention, the work of keeping disease at bay. It also extends to health promotion, those efforts directed at helping people become and remain healthy in the first place.
Success across this expanse depends on two systems, only one of which is even close to fully functional in our culture. Those two systems are disease care, and health care. The election has obvious and profound implications for both.
The disease care system is robust in all the obvious ways. We have superbly trained clinicians in this country, and the best of both technology and pharmacology. There is a case to make that we have the best disease care expertise and resources in the world.
But the system is also flawed in all the obvious ways. Unlike almost every other developed nation on the planet, the United States does not treat access to basic health care as the human right it ought (in my opinion) to be. The result is that many people have no access at all, until or unless an actual calamity removes all choice from the equation.
The Affordable Care Act was a half-hearted attempt to fix this. Why half-hearted? Because many members of Congress wanted it to fail, and imposed constraints- thinly veiled sabotage, really- to make sure it would. We are seeing the results now. The Act has, as intended, provided access to millions who didn’t have it before; has made insurance coverage stable when employment is not; and has spared us all the threat of becoming uninsurable once tagged with a “pre-existing condition.” The sabotage, however, precludes the intended effects on costs of care- so they are, predictably, rising.
The flaws can, indeed, be fixed by a government so inclined- and one candidate favors this effort. So do I. Frankly, I think we should go further. A single-payer system for all could be called by another name: Medicare for all. How is it we are happy with a single-payer system for the segment of the population that actually needs the most disease care, but recoil in horror at the prospect of extending it to the rest of us? It’s a textbook case of effective propaganda, and its triumph over anything like understanding.
A system devoted to the propagation of health, at its origins is arguable more important still. Those origins are, proximally, rooted in lifestyle and behavioral choices we make every day: our diets, our physical activity patterns, our use or avoidance of toxins like tobacco, and so on. The evidence we have indicates clearly that healthy behaviors prevail where a health-promoting culture prevails, and fail everywhere else. However much we might like to harangue one another about personal responsibility, the global story is one of the choices we have dominating the choices we make.
No refinement of clinical counseling is likely to overcome the pitfalls of a culture that peddles multicolored marshmallows as part of a complete breakfast, and sanctions the marketing of willfully addictive junk food. One candidate will oppose the prioritization of short-term profits over the health of children, and the other most certainly will not. I have a preference.
Underlying lifestyle are the social and environmental determinants of health. There is no human health to worry about on a planet ill-suited to thriving Homo sapiens, and from climate change to aquifer depletion, over-population of our own species to the mass extinctions of ever more others- we are heading in that very direction. Now is a time of critical, planetary vulnerability.
Debate about our direct role in climate change is a distraction, and not just because the weight of evidence is rather clear. Rather, it doesn’t matter. It’s happening now, and we here now- and whatever the constellation of causes, we can be part of the solution, or part of the problem. No evidence whatsoever indicates our own species is immune to the threat of extinction we sow so readily.
One candidate is committed to addressing these matters; the other, to refuting the obvious reality of them. I have children whom I hope will have children, and they will all need a habitable planet; so I have a preference.
Public health and politics are inextricably linked. The outcome on Tuesday will say much about the state of their union.
-fin Dr. David L. Katz;www.davidkatzmd.com; founder, True Health Initiative
