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.

That’s nice.

Given the resistance to funding science, I don’t want to suggest that we shouldn’t have a super collider. But it got me to thinking about what would happen if we invested a similar amount in behavioral science solutions to our most pressing problems.

Having witnessed the destruction of two Japanese cities, people have little doubt about the power of physics. But the power and progress of the behavioral sciences is a well-kept secret. In the past 40 years, behavioral scientists have learned how to treat or prevent each of the most common problems of human behavior, including crime, depression, anxiety, drug abuse, academic failure, and marital discord. If we haven’t achieved widespread reductions in these problems, it’s only because we haven’t translated that research into widespread action. So here’s my $8 billion, 20-year plan for a better society.

So, here’s my eight billion dollar, twenty year plan to get us to a society with much less crime, mental illness, and conflict.

Start with making sure that every baby develops successfully. The Nobel Laureate economist James Heckman analyzed the value of investing in early childhood success and concluded that there is a substantial return on investing in infants’ and young children’s success.

David Olds and his colleagues did a series of experiments over the past twenty years showing that putting $7,000 per family into good support to high-risk pregnant moms pays a $41,000 dividend in reduced maternal welfare, less child abuse and neglect, and lower rates of crime when kids reach adolescence.  Olds is already disseminating his program; more than 20,000 families around the country are receiving it. Let’s put $100 million a year into this program over the next 20 years and improve the lives of 285,680 children, their families, and their neighbors.

Then let’s bring Positive Behavior Support (PBS) to every school in America.  PBS is a scientifically based system for teaching and rewarding positive social behavior. Teachers explicitly demonstrate what it means to be cooperative and prosocial in every setting in the school. They use a web-based system for tracking students’ behavior.  Teachers substitute praise, reward, and gentle teaching for criticism and punishment. Schools with PBS have less bullying, safer and happier students, and better academic outcomes.  There are about 95,000 schools in the U.S. So far, about 7500 are implementing PBS.  For a hundred million a year we could get PBS into every school in America.

For another two billion over twenty years, let’s bring scientifically validated family supports to every family that needs them. Scientists have done at least fifty careful experiments on how to help families become more nurturing. These programs show parents how to reduce punishment, gently set effective limits, and reinforce the skills and activities that children need to develop successfully. Such programs reduce drug abuse, aggressive social behavior, and academic failure.  If they were available to every family that needs them, we could prevent much of the delinquency and drug abuse that plagues our communities.

For another billion dollars, we might use the media to teach every
American about the core features of nurturing environments. All of the programs I mentioned encourage people to create environments that minimize stress and aversive stimulation, richly reinforce desirable behavior, and foster acceptance. We reduced smoking by telling people about the harm of behavior, why not encourage people to make their home, school, work, and community environments more nurturing. The benefit of doing this isn’t well-established the way these other programs are, so let’s spend that last billion on evaluating this campaign for nurturance.

A project I led at the Center for Advanced Study in the Behavioral Sciences concluded that youth with multiple problems cost the nation more than $400 billion a year. The Washington State Public Policy Institute has provided solid economic analyses showing that interventions like these can significantly reduce such costs. Imagine that we spent $8 billion over the next twenty years on getting these science-based prevention programs widely and effectively implemented.  We might cut the number of youth with multiple problems in half and save far more than the $8 billion we spent.

That just might be more valuable to the world than learning how to tele-transport a person from point A to point B. Especially if point B is ridden with crime, drug abuse, and depression.

Acceptance is a key to healthy living and loving relationships. While I could cite the science of this to the nth degree, I think illustration is useful.

As I write this I am waiting at the Arizona Cancer Center; it is my 15 month checkup, after the amputation of my right ring finger for what is called, subungual melanoma—a very rare cancer under the fingernail. The Center has only had five cases, and this
is one of the world-class places for the treatment of melanoma.

The atmosphere of the Center is both calming and anxiety provoking. The beauty of the place calms one, as it is exquisitely decorated resembling the most beautiful hotels in our achingly beautiful desert. Worried faces populate the waiting areas; hushed tones whisper fears. Head scarves cover the insults of chemotherapy—not as a symbol of faith in God but faith in science to heal or avert cancer.

“Will it return?” reverberates in my own mind, waiting to see my favorite oncologist. He jokes, “I better be your only oncologist.” It is the black humor that passes between us.

Acceptance is but the one thing I can do to prevent a return of, or restrain, the cancer cells in me and in all of us. I recall being scanned by giant machines that image my body. I recall inviting those cells to find some other space to live in the world or not harm my body as they sought to live as alien Darwin machines in me.

I had heard their faint song in my body some 2-1/2 years ago. How did I hear them? A story begins the saga. When I was twenty, I was very ill from mono in college. One of the psychiatrists at the student hospital at my university had me take the Minnesota Multiphasic Personality Inventory (MMPI). I scored two standard deviations above the norm among men for sensitivity to bodily functions. The psychiatrist seemed concerned by this, though I clearly did not present as a Munchausen case seeking attention for every sensation as years went by without needing to see a doctor—until my recent quarterly ritual visits to the Arizona Cancer Center.

Acceptance at a personal level is more than about thoughts. Acceptance embraces feelings and sensations, too. Acceptance is about noticing and welcoming thoughts, feelings and sensations—pleasant or not.

So how did the acceptance—manifested by higher levels of sensitivity to my own body sensations—play out in my cancer. I am an N = 1 project, which my oncologist points out is the only relevant issue considering one’s own health and sickness.

Here is the flow of thoughts, feelings and sensations that unfolded with my own cancer. I felt the nail split on my right ring finger on vacation in June of 2006, and it grew inflamed where the nail knifed into the nail bed. The split and inflammation persisted, and I brought it to the attention of my primary care doctor—a good man who carefully listens to me. He cultured the nail bed for fungus and ordered some antibiotic crème, which reduced the inflammation. Healing did not happen, so I asked for a referral to a dermatologist. More crème and an oral antibiotic. It looked better but did not heal. Then a punch biopsy that hurt like Hell, but showed only odd granulated cells. My sense and feelings of unease persisted. I could see oddities, and something in me communicated all is not well throughout my body. I asked for a referral to a hand surgeon, thinking a resection—cleaning out—of my nail bed might jumpstart the healing, as the granular cells were a sign of disrupted intra-cellular communications that do manifest in cytokines communicating with the central nervous system. I wondered if that might be the unease I sensed in some weird way.

I did not take the advice of many who said, “Just pay no attention. It will heal on its own.” That felt like avoidance to me. The wonderful hand surgeon did a resection. I had bratwurst for a finger the next day as I flew to Eugene to work with Tony. He wonderfully changed my bandage, with such tenderness and concern.

My sensations and feelings of “wrongness” persisted, despite the surgery. I had thoughts that my finger would need to be amputated to save my life, and I even had unwelcome thoughts that this would happen on my birthday—the day before Thanksgiving in 2007.

A few weeks later, my surgeon called while I was giving a lecture on evidence-based kernels to psychology students at the University of South Carolina. I finished the lecture, and he called back. He had two biopsies performed on the tissue from my finger; he was not happy with the first, as it was inconclusive. He did not dismiss his thoughts. The second more detailed biopsy showed it was melanoma in my finger. This was terrifying as such melanoma is rarely discovered before Stage 3 or 4, and carries high mortality.

My hand surgeon had arranged for me to be seen within the week by the Arizona Cancer Center for the surgery workup, which would certainly lead to an amputation of my right ring finger to prolong or save my life. That surgery did happen, on my birthday, as that was the only open time in the operating room.

Then, Thanksgiving came with that long weekend. I would not hear from the biopsy of my finger or my lymph nodes for 7-10 days. Then, I would know scientifically what stage my cancer was and the nature of my future treatment and survival probabilities. On that Sunday of Thanksgiving weekend, I was learning to peck at the keyboard to answer emails from the outpouring of love and support, when new thoughts, feelings and sensations came to me. Yes, I had pain—including phantom pain—in my finger and under my arm. There was something ineffably different, however, in me. I no longer felt the cancer talking to me through those cytokines, that seemed to generate the ever so slight uneasy thoughts, feelings and sensations that I had come to know and accept. Those tiny thoughts, feelings and sensations were entirely absent, no matter how hard I tried to find them internally. That was when a thought came to me: “The cancer is gone; I—that sense of transcendent self—am OK.”

Four days later, my oncology scheduling person—Lindy—called me, who I had bonded to. There was joy in her voice, as she told me I had no lymph node involvement and a Stage 1 tumor. This was a good as it could be at that moment. Today, as I write this is 15 months sense those events, and all the tests to date show no cancer.

All of this is a story of working at acceptance—noticing my thoughts, sensations and feelings, including the ones that were and are so unpleasant. As I write this, I can see had I not embraced those thoughts, feelings and sensations, I might be facing a far more uncertain health path.

Today, I hypothesize that acceptance of one’s own thoughts, feelings and sensations leads to better self-care. Such acceptance enables people to make early choices to act for health and well-being, as one notices the currents of physiological and psychological processes in response to context and history. We may not have a language to describe the song of cytokines calling to our immune and central nervous systems. We can, however, accept that they do scientifically “sing”, and we can sense that via the complex thing we call our brains.

I no longer hear the cancer sing. Perhaps, they heard my invitation to move on or live quietly without harming me. I accept that they can come back, welcome or not. Now comes my commitment to live a healthy, well life filled with good friends and love as well as daily works that fit my goal to better the world.

CODA:

We have good data to suggest that acceptance is related to health, and I expect that science will grow. Just today, I received notice of a scientist who published a prospective, randomized study of breast cancer patients who received psychological support. Women who received such support were 45% less likely to have cancer return and 56% less likely to have died from cancer.1 To make use of such support, one must accept all the thoughts, feelings and sensations that come with cancer.

References Cited

1. Barbara L. Andersen H-CY, William B. Farrar, Deanna M. Golden-Kreutz, Charles F. Emery, Lisa M. Thornton, Donn C. Young, William E. Carson III,. Psychologic intervention improves survival for breast cancer patients. Cancer 2008;113(12):3450-58.