We might never know the true ben­e­fits of ef­forts to im­prove pub­lic health

Modern Healthcare - - Front Page - DAVID MAY As­sis­tant Man­ag­ing Edi­tor/Fea­tures

Preven­tion ef­forts are run­ning into some cu­ri­ous hur­dles

Some­times it seems as if the term “preven­tion” has be­come the equiv­a­lent of a four-letter word.

With in­creas­ing fre­quency, gov­ern­ment ini­tia­tives in­tended to ap­ply some preven­tive ap­proaches to our nation’s pub­lic health chal­lenges are met with sus­pi­cion if not de­ri­sion.

First lady Michelle Obama cer­tainly knows all about that, given the scorn heaped upon the pro­gram she is spear­head­ing that tar­gets child­hood obe­sity. The ini­tia­tive, dubbed “Let’s Move!” and now a year old, never should have been a con­tro­ver­sial en­deavor.

What’s wrong with find­ing new ways to en­tice kids to step away from the TV or Xbox for a while and prod them into get­ting some ex­er­cise? Isn’t it a wor­thy ef­fort to nudge our nation’s schools to of­fer less “junk” in the cafe­te­ria and more nu­tri­tious yet tasty choices? Chef Jamie Oliver has made it his mis­sion to prove that it’s not only pos­si­ble to do this, but kids even like it.

Of course the crit­ics of Obama’s ini­tia­tive saw it as just more waste­ful spend­ing. And they warned of “food po­lice” tyranny and the “heavy hand” of gov­ern­ment rob­bing our youth of their trans-fats.

Yes, bil­lions of dol­lars are at stake in gov­ern­men­tal preven­tion ef­forts. And we know that in large-scale ini­tia­tives, the num­bers of­ten don’t add up, at least if the met­ric is health­care cost sav­ings. The “re­turn on in­vest­ment” of­ten dis­ap­points be­cause the pro­grams of­ten be­come cost driv­ers, at least ini­tially, rather than sav­ings gen­er­a­tors. But that’s not the fi­nal word.

In our May 9 cover story ti­tled “Does preven­tion re­ally pay?” the take­away is that there re­ally isn’t a cut-and-dried an­swer to the ques­tion. How­ever, as one ex­pert noted, at­tempts at quan­ti­fy­ing sav­ings from preven­tion ef­forts can “vastly un­der­es­ti­mate the cost-ben­e­fit … be­cause they don’t in­clude all of the in­di­rect costs and ben­e­fits in­volved.”

One of the most re­cent as­saults on com­mon-sense preven­tion ef­forts comes cour­tesy of the Florida Leg­is­la­ture, which this spring ap­proved and sent to Gov. Rick Scott a bill that aims to muz­zle physi­cians—most specif­i­cally pe­di­a­tri­cians—in their at­tempts to head off se­ri­ous in­juries. The is­sue? Guns. The bill, with some crit­i­cal ex­cep­tions, makes it il­le­gal for doc­tors to ask pa­tients about whether they have firearms in their homes. Such ques­tions are of­ten asked dur­ing well-child check­ups as part of coun­sel­ing new par­ents about com­mon haz­ards in the home and how to mit­i­gate them. To spon­sors of the bill, how­ever, the ques­tions are an in­va­sion of pri­vacy.

The fines are set at $500 and can es­ca­late for mul­ti­ple of­fenses. Ear­lier drafts of the bill in­cluded im­pris­on­ment and fines of as much as $5 mil­lion. All for ask­ing a ques­tion that just might pre­vent the in­jury or even death of a child. Ac­cord­ing to a na­tional es­ti­mate from the Cen­ters for Disease Con­trol and Preven­tion, there were nearly 3,600 un­in­ten­tional non­fa­tal firearms in­juries among those age 19 or younger in 2009.

What about the free-speech im­pli­ca­tions of the bill? This is a pa­tient-physi­cian con­ver­sa­tion in which doc­tors also might ask about many other po­ten­tial haz­ards such as ac­cess to swim­ming pools, poi­sons and toxic house­hold prod­ucts. Are those of­flim­its, as well?

The ques­tions are no threat to Amer­i­cans’ Sec­ond Amend­ment rights. They have been asked over the years and clearly haven’t in­hib­ited gun own­er­ship. And it’s al­ways the pa­tient’s choice to de­cline to an­swer.

What’s spe­cific to guns is just how un­for­giv­ing an ac­ci­dent can be. And tod­dlers seem to have an un­canny knack for find­ing ob­jects that par­ents thought were safely locked away.

This is leg­is­la­tion that should be locked away. Do­ing so could prove to be some highly ef­fec­tive preven­tive medicine.

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