Prevention advocates like to tell the story of the town next to a river where drowning people keep floating by. The town stations boats and an EMT crew on the river to save as many as they can. Sometimes they succeed; often they fail. But no one thinks to go up river and see why all these people are falling in. The preventionist does.
In the case of health care reform, it is as though America has decided to move its rescuers half way to the spot where people are falling in. For example, the Senate Committee on Health, Education, Labor and Pensions’ proposes to fund “basic preventive services such as screenings, for diabetes, depression, and colorectal and other forms of cancer, tobacco cessation, and nutrition counseling.” Such screening will prevent many people from developing life-threatening illnesses. But the Congressional Budget Office argues that the cost savings would be minimal.
We would do better to go all the way up stream to the source of these problems. We need to prevent children and adolescents from developing the psychological and behavioral problems that contribute to serious illness.
Young Americans who develop depression, antisocial behavior, tobacco, alcohol, and other drug use, academic failure, or obesity will become the sickest Americans. Each of these problems contributes very substantially to physical illness. For example, boys who are aggressive as children and adolescents are at greater risk for heart disease. Aggressive children are also more likely to fail in school, take up cigarette smoking, become addicted to drugs, and become depressed—all of which are risk factors for physical illness. Similarly, depression increases the risk of heart disease, strokes, and diabetes. Waiting until people develop these problems and then treating them in order to prevent cancer and heart disease will be much more expensive than preventing them in the first place.
Fortunately, there is substantial evidence that these problems can be addressed through behavioral interventions. A just-released report of National Research Council and Institute of Medicine enumerates interventions that prevent the development of multiple problems. Interventions for poor, stressed young women that support them during their pregnancy and the first two years of their child’s life can prevent child abuse, welfare dependency, and even the children’s delinquency in adolescence. There are numerous carefully evaluated family interventions that can prevent the development of aggressive behavior and all of the problems that result from it. There are programs that can prevent depression. There are nurturing school interventions that can produce extraordinary results. For example, Sheppard Kellam and his colleagues showed that a simple game, played in first grade, which rewards children for cooperation and doing their school work, can prevent the development of substance use, suicidal behavior, and antisocial behavior when the children are adults!
Many of these interventions are cost-effective. They save more in criminal justice, health care, and education costs than they cost—sometime by substantial margins.
The NRC-IOM report urges that the logical next step is to widely disseminate these proven preventive interventions. That will require further research to develop and test strategies for making these valuable interventions widely and effectively available. Their call is in keeping with President Obama’s proposal to fund “Promise Neighborhoods” that would be modeled after the Harlem Children’s Zone and provide comprehensive supports to families and schools to ensure every child’s successful development.
Unfortunately, these efforts are not receiving the support they deserve. As the IOM report documents, prevention research receives only a tiny portion of the funding from the National Institutes of Health. And although the NIH has been trying to inspire ground breaking innovations in research through their Roadmap initiative and the “Grand Opportunity” initiative, the emphasis on these initiatives is almost entirely on neuroscience, medical, and biological research. For example, the review committee for a recent proposal we submitted for research in high poverty communities was reviewed by a panel that had only one behavioral scientist. Not surprisingly, it did not fare well.
The IOM report calls for the White House to take the leadership on this problem. Currently, we have myriad agencies of the federal and state government charged with addressing one or a few of these problems—despite the fact that the problems co-occur and stem from the same set of environmental conditions—poverty, harsh parenting, stress. Moreover, like the town by the river of drowning people, most of our resources are going to treating problems, rather than preventing them. With White House leadership it would be possible to develop a coordinated, comprehensive strategy to gets preventive interventions widely and effectively deployed. Doing so would reduce health care costs as well as all of the increasingly burdensome criminal justice costs.
Tags: Prevention
There are unprecedented opportunities with this new administration to truly make a difference in the onset and escalation of disease and disorder by refocusing our efforts on suboptimal environments conducive to dysfunction which we have tolerated for so long. The unfortunate reality, as expressed by Dr. Tony Biglan, is that the downstream focus on disease and disorder after it develops has persisted despite years of prevention research documenting that environmental and behavioral interventions have potential to not only ameliorate or reduce the severity of problems, but to prevent their occurrence altogether. As stated, behavioral and psychological problems such as aggression, drug abuse, overeating, unhealthy diets, alcoholism, academic failure, depression, traumatic stress, etc., are associated with tremendous financial, health, and public safety costs. Yet, the congressional budget does not reflect on the part of its authors an understanding of these problems and the potential for preventing them. Research that employs a “systems approach” from a transdisciplinary perspective and using multiple tools to understand the development of these problems, are most likely to shed significant light on their sources. Restricting our focus to conditions proposed by any one discipline (e.g., social factors, neurobiological function, etc.) will continue to address only part of the equation. Rather, integration between disciplines, from the social and environmental sciences to neuroscience, is critical to view the whole picture and all of its components in any study of complex human behaviors. And given what we know to date – that the underpinnings of these problems are malleable – investing in this research will no doubt produce an extraordinary cost-savings and at the same time improve quality of life for many.