As I write this, the Prevention Fund is about to undergo -- or has just undergone -- a $5 billion amputation.
For those of us dedicated to disease prevention and health promotion, this is a very cruel cut indeed. The Prevention Fund is a key element in the Affordable Care Act that allocated funds to both clinical preventive services and community-based health promotion programming.
There are, in my opinion, four reasons why this fund -- and prevention/public health in general -- are vulnerable now and always to the peril of martyrdom as political deals are being struck.
First, prevention at its best is as dull as watching paint dry. I say this as a preventive medicine specialist with true reverence for the field. But let's face it -- a heart attack that doesn't happen lacks drama. The bout of influenza someone doesn't get lacks flare. When prevention and public health work well, you see just about none of what you get. You get a lot, and see... nothing.
Second, prevention takes time. Political life cycles are short. The benefits of funding prevention now will accrue too late to influence the outcome of the next election.
Third, public health has a very serious identity problem; namely, no one can identify the public. This problem was put in the spotlight most recently by Whitney Houston's untimely and tragic death.
Two reactions to Ms. Houston's death populated the messages that came to my attention by various media and means. The first was sadness and sympathy. The second, though, was disparagement of all that sadness best expressed this way: "One dies, millions cry; millions die, no one cries." Messages of this variety referred often to such calamities as the earthquake and aftermath in Haiti, genocide in Rwanda or famine in the Sudan. The objection, of course, was that while tragic, Whitney Houston's death was no more tragic than untold others that played out in obscurity.
But, of course, it's not true that no one cries when millions die. When millions die, many more millions cry. But those millions aren't us; they are the family members and friends of each of the countless casualties of the particular disaster. When the disaster is in our neighborhood, we are among those who cry. When far away, generally we are not.
In some ways, of course, it's a good thing we don't feel every loss too intimately. If we did, I'm not sure any of us could bear the load. There are tragedies every day. Were we not somewhat insulated against them, they would quickly bring the strongest of us to our knees.
But there is, as well, a great liability for public health in this insulation. When we talk about what prevention could do -- eliminate 80 percent of all heart disease, 90 percent of all diabetes, up to 60 percent of cancer and so on -- it is all in terms of some anonymous public. We are hard-wired to shrug our shoulders about that, and carry on. In contrast, Whitney Houston had a name and face and voice we all knew -- and for the loss of that, we readily feel passion and shed tears.
But consider for a moment the people you love who have been touched by heart disease, cancer, stroke or diabetes. Recall the visit to the hospital, the dreaded phone call. Now consider that prevention funds, used wisely, could make that experience go away fully eight times in 10. Prevention funds, used wisely, could help us give our children a world in which those horrible phone calls and anxious trips to the ER and ICU are mostly gone.
It's all too easy for the prevention fund to be about a public with no face and no name. But when we part the veil of statistical anonymity, the faces looking back at us are the faces of people we love. Those in Congress swinging the axe simply didn't pause to part the veil.
Lastly, there is the difficult issue of trade-offs. As a preventive medicine specialist, I would see few greater priorities than the prevention fund, even if its spreadsheet didn't affect me directly. As it happens, it probably does, because funding for the nation's prevention research centers -- including the one I direct -- depends partly on that fund. A cut to the prevention fund will almost certainly mean a cut in funding to my own lab.
But that's just the point -- a cut in ANY funding is personal to somebody. If the prevention fund were not being gutted to pay for extension of the payroll tax cut or provide ongoing unemployment benefits, what would be? Money, ultimately, is available in less abundant supply than the ways to spend it.
If prevention is up against education, which should be the priority? What about a choice between classroom size, and military preparedness? Clean energy, or keeping roads from falling apart or bridges from falling down?
Given what I do, it's no great surprise that I can think of few worthier causes than preventive medicine, a discipline dedicated entirely to the methods and means, programs and policies that obviate a great deal of avoidable human misery. We do, indeed, need more support for this field, which has long taken a back seat to the greater drama, but lesser benefits, of acute care.
Even so, I am generally ambivalent about calling my members of Congress to ask for money.
What I can't know is this: If more funds are allocated to these highly deserving efforts, what programs will be eliminated to compensate? What would the trade-offs be?
Earmarks are the sort of thing everybody loves to hate. But hot rhetoric and well-cooked propaganda generate a lot of smoke, even where there isn't much fire. One man's earmark is another woman's very worthwhile crusade. Earmarks are, fundamentally, line-item additions to legislation about something somebody cares about.
The earmarks we consider earmarks are the things other people care about and we don't. If it's a program that matters to us, it's no earmark -- it's a cause. And most of us would be happy to share an earful about why.
Any program addressing the nation's crises of obesity and diabetes, poor diet or lack of physical activity is a worthy contender for funding in my book. And that's true even when the program is active only locally, since public health espouses a "Think globally, act locally" philosophy.
But I certainly understand that what's local for me is far away and unimportant to someone else. I rather doubt a member of Congress in Idaho will fight for any program, no matter how laudable, here in Connecticut. Nor should we expect a senator in Nebraska to ignore a worthwhile program there, simply because there is some other program in Idaho -- that only serves residents of Idaho -- that might, in direct comparison, be the superior program. In fact, any senator that fails to fight for the interests of his or her constituents is unlikely to remain a senator long!
Ideally, someone would weigh each part against the sum, and figure out how best to put the puzzle together. What array of programs relevant to public health, for instance, would produce the greatest net improvement in health for the greatest proportion of the public? No one is doing this job, and it's not even clear just how anyone could. Consider the daunting task of judging every conceivable combination of programs across all states to define the combination that is the most productive, and most cost-effective.
In the absence of that Platonic and perhaps unfeasible task, what we are left with is advocacy: people fighting for programs they believe in.
Don't we want our friends, senators and representatives to lend us their ears when we come before them with the causes that incite our passions? When they successfully defend such causes in the rough and tumble of Congressional budgeting, aren't they doing what they were sent there to do? The only alternative to the perfidious earmark is, it seems, for our members of Congress to turn deaf ears to our entreaties.
The trouble with listening, though, it that you'll tend to hear whoever shouts the loudest. Generally, the deeper the pocket, the bigger the megaphone.
In the current round of advocacy and political wrangling, there were winners. But because of competing priorities, our common failure to see the personal reasons for passion in public health, the slow return on investments in prevention and the lack of drama when dreadful things don't happen -- prevention was not among them. For that to change before next time, our perspective will need to change first.
For more by David Katz, M.D., click here.
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