Saturday, April 19, 2008

A pound of prevention barely worth an ounce of cure

Michael F. Cannon has a blog post at about preventive medicine.

While I've always thought that prevention of disease would be less costly than treatment, that is only true, when we stop to ponder it, when the total cost per person treated with some preventive measure is less than the savings in cure costs. That means that the total cost per person treated or per preventive measure would have to be lower than the difference between the cure expenditure with and without prevention. Furthermore, those costs have three categories: direct costs, indirect costs, and abstract costs.

You there at the back! Please don't yawn unless you've got enough for the rest of us.

Where was I? Oh, yes. The direct costs are the costs of shots, educational materials, and so on.

The indirect costs include the time off work going to get some preventive treatment, the loss of efficiency when some supposed safety control is implemented, and the added bureaucratic sludge that happens whenever we try to prevent something bad by changing the behavior of everyone.

Abstract costs include the loss of freedom for the individuals who are given the prevention.

Nestled invisibly between the indirect and abstract costs of preventative medicine is what it does to people's opinion. Much of preventative medicine consists of "raising awareness" of the problem, so that people can avoid stepping into open pits and so forth.

But if told too many times about an open pit, or a hot stove, or dangerous intersection, people will be filled with thoughts only of safety and precaution, aftraid to risk opening their eyes lest ultraviolet radiation damage their unprotected corneas. They exist only to be safe.

Alternatively, the more preventive measures we implement, the more jaded the people become and the more difficult it becomes to raise their awareness to a preventive level.

But the key problem is that for prevention to work, the pool of those treated with the preventive measure must be larger than the number cured, in many cases far larger. Taken together, and since prevention must be applied to the wider pool while remediation only to those affected, the cost of the prevention must be very low, and its effectiveness very high, for prevention to make sense.

Depending on the depth of the pit and the type of snakes at the bottom, it may be more cost-effective and indeed more humane to wait for someone to step into the pit and throw them a rope. Put a sign on the pit perhaps, but don't develop a slick ad campaign to tell people to avoid the pit, which will likely draw more people to it anyway.

This all yields the best quote ever on socialized medicine:

The point of the medical-care system is to serve people. It is not the point of people to serve the medical-care system.
-- Louise B. Russell

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KnightErrant said...

I agree with some of your argument. There is too much fear of risk. I don't often use anti-bacterial soap because I don't fear most germs; my body has an immune system. I am contemptuous of the wilderness trekker who bring a cell phone and GPS in the event he gets an ingrown toenail and needs a helicopter evac.

However, viewing preventative medicine as a purely actuarial exercise misses something important. How do you value suffering and loss?

Let's say a coal company concludes it is more cost effective to pay the medical bills than providing all the equipment to prevent Black Lung Disease. Which should the company choose? How do you place a value on the suffering and early death Black Lung causes?

Preventative medicine serves two main purposes - avoiding epidemics and preventing needless suffering. Even if it is more expensive it is better to prevent polio than treat it after the infection. That is the meaning being the "ounce of prevention" aphorism.

Loren Heal said...

Oh, I agree that for some things -- black lung disease, malaria, AIDS -- prevention is preferable even if it is not financially efficient.

But there comes a point when prevention is more harmful than remediation. Your anti-bacterial soap is a very good example. Plain old glycerin soap and water, plus mechanical action, removes 99% of everything on the skin, including microbes. To get from there to 99.9% we introduce chemicals which kill predator bacteria, leaving the nastiest buggies free to attack us.

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