Sunday, September 25, 2011

An ounce of prevention

My sons' tastes run to the macabre.

We were on holidays in Newfoundland in August, and climbed Gros Morne Mountain.  As we were scrambling up the scree, they began to discuss the chance of an avalanche.  Specifically, they wondered about the possibility that we would be trapped by boulders.

"Hey, it would be just like that guy who got trapped when he was hiking and he had to cut off his own arm with a pocket knife!" said one.

"Yeah, he's famous now," replied his brother.  "They just made a movie about him."

In 2003, Aron Ralston had gone hiking alone in Utah without telling anyone where he was going.  After having his arm pinned by a dislodged boulder and spending 5 days (the movie is called 127 Hours) without food or water, he freed himself by amputating his forearm.  He was found by other hikers, and taken to safety.

I remember thinking back then, as Ralston was celebrated as a hero on TV news and talk shows, that although he had showed incredible will and courage, perhaps his ordeal could have been prevented or shortened if he had taken the elementary precaution of telling someone where he was going, and when he could be expected to return.

An ounce of prevention...

This story came to mind again at the end of our holidays when we were visiting in Newmarket, Ontario.  I was walking by Southlake Regional Health Centre and saw these signs:

Before I go any further, let me make this clear: I am not making light of the contribution of this Health Centre.  I am not minimizing any illness that the pictured lady or any other patient suffered, nor the important role medical care plays in treating and curing serious disease.  These signs are representative of many others used in hospital fundraising campaigns across the country.  I am not singling out Southlake; it was just a coincidence that I was passing by their hospital while thinking about this issue.

In healthcare, most of our attention is on acute and chronic care: heart disease, cancer, diabetes and trauma, for example.  Our taxes and charitable donations build hospitals and furnish them with the latest technology.  We pay specialists handsomely to perform complex, life-saving procedures.  We marvel at the latest advances in medical science.

Many people will say, "Of course our attention is on acute and chronic care! What else is there?"  There is Acute and Chronic's demure sibling, Prevention.

It's often said that prophylactic measures, such as clean water and vaccinations, have had more impact on improved health than any other intervention.  But, how many $500 a plate dinners raise funds to promote eating more fruits and vegetables?

Prevention gets less attention for a number of reasons:

Its beneficial effects are not seen for many years, making it difficult for us to link preventative measures to beneficial outcomes.  Those in charge of health care budgets may find it difficult to allocate scarce funds today, when the benefits will not accrue for decades.

Its value is measured across populations. When individuals enjoy good health, it's seen as a normal, baseline state, and not because of some intervention on their behalf. 
The least economically and politically powerful among us may be the ones who benefit most from preventative measures such as smoking cessation, and education about diet and exercise.  

I've heard acute care medicine (derisively) referred to as "rescue medicine".  The point is that health care systems include the maintenance of healthy populations in their mandate, yet they spend many of their resources saving people whose disease could have been prevented in the first place.   What if that kind of contrarian thinking became the norm?  What if we noted the known risk factors for every condition that forced someone's hospital admission, and so kept a running tally of the daily cost of each risk factor?  We would expect hefty government investment in smoking cessation, and promotion of healthy diet and exercise, as a start.

Perhaps the information on Southlake's signs ("40,000 patients and counting") should be seen as a sign of our health care system's failure to prevent disease, rather than a rallying cry to promote expansion of health care facilities.


  1. Perhaps your next post might be a meditation on the comparative merits of Saskatoon's children's hospital compared to investments in prevention, health promotion, and primary care.

  2. Thank you Dr. Kishore, along the same lines I would like to point out that this does not apply only to healthcare but nearly all aspects of tragedy in life. In spite of the Nobel Peace Prize, compare the popular status of:
    - soliders vs foreign civil service,
    - SWAT police vs block parents, or
    - social workers vs policy advisors.
    Even the language "front line workers" suggests that there is something more noble and "real" about the recvovery than the prevention.
    Indeed, under the Canadian charity laws, if you provide the "rescue service" it is worthy of a tax receipt but if you prevent the harm in the first place that does not qualify. (e.g. Advocating for high-school sport programs as a means of preventing kids from dropping out.)

  3. Thank you Anonymous (#2) who raised some amazing and poignant analogies. And thanks Kishore for encouraging us all to take a slightly different perspective of things. Perhaps we should be encouraging, supporting, and yes, even funding, primary care and primary care health centres as a more proactive approach to improving our community's health!

  4. Thanks for these great comments!

    Anonymous #1 - very timely thought. Last week, Sask Health announced $1.4M for children's preventative dental care for communities with highest risk of tooth decay. The Minister of Health indicated that, in Saskatchewan each year, 1,800 children under age 5 undergo dental surgery under anaesthetic! Imagine what an impact prevention will have - and with prompt, measurable results too.

    Anonymous #2 - I agree with tpa. Thanks for pointing out how pervasive our focus on "rescue service" is.

    tpa - If we were to better fund primary care and prevention, where would the money come from? Right now, I believe almost all funding for this comes from the government (not necessarily a bad thing, but there is this 4-year election cycle ...), and I'm not aware of any significant philanthropic effort, beyond that of environmental groups trying to keep our clean water and air. (Someone weigh in on this and correct me, please!) Here's a challenge for a final year business student: Come up with a business model for an NGO that promotes and funds preventative health initiatives in Saskatchewan.

  5. We already have that in Saskatchewan! The Saskatchewan Prevention Institute. Obviously it doesn't get the attention (nor the funding) it deserves. Currently its focus is on children's preventative health initiatives.

    This is from their 2010-11 Annual Report:
    Formed in 1980, the Saskatchewan Prevention Institute, is a non-profit organization that works to raise awareness and educate the people of Saskatchewan, focusing on the promotion of primary prevention. We are an organization, with a strong vision ... “to reduce the occurrence of disabilities in children”.

    We bridge the gap between research and programming, transferring knowledge to both the public and professionals.

    (Do I still get course credit?)

  6. Thank you so much, Anonymous #3, for informing me! This is a great lead that I will pursue. You get an A+!

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