I keep hearing all this talk about how the emphasis in medicine needs to be on prevention of disease, and not disease management or cures. As a nurse with over 20 years experience in a variety of clinical and business settings, most recently in mental health, I would like to suggest the new paradigm of prevention first is a bit mis-guided and unrealistic.
First, what is prevention? How do you realistically "prevent" obesity, high blood pressure, diabetes, heart disease? There are only 2 ways to affect these chronic diseases: education or dictate. The health community has focused on education for 40 years. Constant repetition on message has slowly changed the numbers of unintended pregnancy, smoking, STDs, and AIDS related illness. There are other examples too, but changing behavior is a slow process. Education alone does not prevent chronic medical problems, at least not quickly.
So the new health reform thinks they can prevent first, limit the expensive care to a few choices at the end of life, and suddenly every one in this country will have excellent universal care that is cost effective, paid for, and even reduce the deficit. Only one problem: you can't dictate behavior.
This is the only way large scale changes could lead to the kind of Utopia one side of the spectrum is envisioning for this county. If you punish behavior that causes chronic disease, it is the only way to effect change rapidly. So, your freedom to choose is taken away, "for your own good" because people left to their own devices will not make smart choices. Outlaw transfats, outlaw tobacco (so why is it still legal if you really want people to quit smoking?) Outlaw sugar, outlaw meat (global warming), remove all snacks except fruit and vegetables from the school vending machines, tax complex carbs to reduce useage, mandate 1 hour of exercise daily for all citizens, fines for BMI over 30, fine smokers. I know - maybe you could just remove food and use compressed supplements with all the recommended nutrition. And those weak humans to do develop diabetes, or high blood pressure, or have too much fat? What do we do with them, after all our "help" controlling their weakness?
Maybe it is time to re-read Brave New World, Farenheit 451, Animal Farm, and Soylent Green. As for me, I prefer the education route, and continue to fund research in to cures. This may be a bit tongue-in-cheek, but this pie in the sky talk about prevention, not cure or treatment of disease seems to ignore the human factor and the gift of free will. I don't want government to take that away from me. Positive reinforcement has always worked better to change behavior than punishment, and yet in this new world of reform, the only way to prevent disease is to punish the behavior that causes it.
