Combating the terror of chronic disease, and vice versa

Listening to President Barack Obama say his official goodbye made me reflect on the space where my professional purview, and my anxieties as a citizen in the modern world converge. Terrorism is like chronic disease, and vice versa.

The relevance of Obama’s farewell to this rumination is the obvious: he took office twice in the post-911 world, and ended his two-term stay in the White House at war with global terrorist organizations. We have seen triumphs, and we have seen disasters, but we certainly see no end in sight.

This somber conclusion took me back to my impressions as a medical resident, training in internal medicine, in the late 1980s and early 1990s. The typical workweek then spanned 100 hours or more, night and day. Almost all of that time was spent tending to hospitalized patients who were very sick. Our mission was a combat mission; we were combating the everpresent threat of decompensation and death.

We were pretty good at it, and the never-ending advances in medicine make us better at it all the time. Death, more often than not, can be forestalled.

But we ourselves are forestalled, now as then, in moving past combat to the solace of success. The hospital was all about people who mostly had serious chronic diseases that never needed to happen, and were never going away. We care providers and our technical wherewithal were and remain all the king’s horses and all the king’s men; and our patients, alas, were Humpty Dumpty. What we could not put together for them was genuine vitality, long gone, and gone for good. Famously, you can’t unscramble an egg.

But Humpty Dumpty conveys another message, more important: why is that fall off the wall necessary in the first place? Let’s put a seat belt up there; or cushions at the base of the wall. Or lower the wall. Or replace it with a bench; who needs to sit on a wall, anyway?

The simple fact is that most of what lands people in hospital beds is preventable. We have known how to prevent roughly 80 percent of all chronic disease and premature deaths for decades.

So, I followed my residency in internal medicine with another, in preventive medicine, and the rest, as they say, is history. For the better part of the past 30 years, I have done both to the best of my ability: combating established disease by treating patients, and working to promote lifestyle as preemptive medicine. Treated disease is better than untreated disease, but not nearly as good as untrammeled vitality.

Which brings us back to the end of the Obama era, with the terrorism war ongoing, our troops still in harm’s way, seemingly never able to leave Afghanistan. These troops are combating terrorism like medical personnel combat disease in the hospital; the situation is already bad in both cases, and the job is to contain the threat.

There is no real victory in either case. The killing of terrorists inevitably begets more terrorists; the war is self-perpetuating. So, too, is a medical model far more devoted to combating chronic diseases it knows how to prevent, than preventing them.

The remedy is a far greater emphasis on prevention. That requires patience, because we cannot prevent what has already happened. If the already sick inspire better attention to health promotion, it is the next generation that will benefit fully. The current cohort gets treatment; the next gets vitality.

If that view pertains to terrorism, too, as seems likely- questions about preventing terrorism a generation from now should be at least as salient as saber rattling. Shouldn’t we be assessing, discussing, and investing in whatever it would require for our children to need bombs and bullets less a generation from now?

The ultimate remedy to terrorism is likely as slow as preventive medicine; desired effects span decades, and generations. Populations stewed in the hate of echo chambers need to die out in time and be replaced by progeny who can find their way to a common humanity through the advent of understanding. Education and opportunity are anti-terrorism vaccines.

Saying so does not make administering them easy. But not saying so, renouncing global connections, and hunkering behind walls — all but guarantee we will simply keep getting, and treating, the same disease indefinitely. Vaccinating the world against smallpox wasn’t easy either, but had we not done so, we would still be treating it.

More focus on prevention could give our children a world mostly free of chronic disease and terrorism alike. For now, both wars rage on- in part because we seem inclined to accept that’s the best we can do. It’s not. We can do better.