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James S. Marks Headshot

Friendly Fire in Prevention?

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It's worth noting that prevention and public health were prominent in the national debate on health reform. And it is a big step that prevention and especially prevention of illness that occurs outside the medical care system got dedicated funding in the new Affordable Care Act -- seemingly a lot of it -- $15 billion over 10 years. While $15 billion certainly is nothing to sneeze at, do the math. In a law that CBO estimates will cost about $1 trillion dollars over the next 10 years, $15 billion is 1.5 per cent. Past estimates show that public health and prevention get less than 5 percent of the health spending pie, so once again it's a negligible slice. Certainly with the size of the cuts happening at the state and local level it probably doesn't even cover the losses that have already occurred, much less strengthen a public health system that is being asked to do more than ever before by the American people -- like preparing for manmade and natural disasters, preventing costly chronic illness and vaccinations during pandemics like H1N1. Yes, we need to make it possible for more Americans to afford to see a doctor and get high quality care, but we desperately need a better balance between repairing our health after the damage has been done and preventing that illness or injury in the first place. Our health starts, and is strengthened and preserved, well before we go to the doctor's office -- like preventing children from beginning to smoke or arresting and reversing the obesity and diabetes epidemics by eating right and being active.

And because prevention resources are so tight, some have lined it up like a good public health heavyweight bout: Tobacco vs. Obesity. A recent New England Journal of Medicine commentary challenged the nation not to forget tobacco, noting the leveling of youth smoking rates after significant declines in the 1990s, and warning that millions will die prematurely. The authors are right to ask that tobacco not be forgotten. But some of the discussion that followed has framed the issue as if it were a zero-sum game, that the nation should work less on obesity because we have not fixed the tobacco problem. Perhaps this is exacerbated by the usual prevention funding that is very specific to one issue or another, unlike health insurance that is for all illnesses. If we head down that path of one critical issue in prevention against another, we all lose. We know -- as does the tobacco industry -- that nearly all smokers start as teens. We also know that an obese adolescent has an 80 percent chance of becoming an obese adult. We need to do all we can to raise teens who never start smoking and young people who learn early to eat healthily and have an active lifestyle.

We have to pay attention to all the major contributors to preventable illness. And tobacco use and obesity are paramount. We must be vigilant to prevent backsliding, as the NEJM commentary noted. We should be clear that as a nation we have done too little to prevent disease, whether from smoking or unhealthy eating or lack of physical activity. We are finding out that the excess illness we have is making it nearly impossible to afford to give good quality medical care to those who need it. The solutions must come from doing more to prevent both tobacco use and obesity.

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