The CDC director argues that it’s in the national interest in terms of money and lives to focus on prevention. Excerpted from “Thomas Frieden,” July 23, 2010.

THOMAS FRIEDEN, M.D., M.Ph., Director, Centers for Disease Control and Prevention; Administrator, Agency for Toxic Substances and Disease Registry

 

There are enormous economic as well as health benefits from prevention. While ultimately it’s the health benefits that are our strongest case, we also – given the economic context that we are in – have to think hard about the economic case for prevention.

There are a series of factors that affect health. The most basic are socio-economic determinants of health: poverty, education, housing, equality; the things that are the substrate in which health occurs.

At the level above that are initiatives that can be thought of as traditional public-health initiatives. Changing the context, so that the default decision is the healthy decision. Clean water, clean air, food that is iodized and water that’s fluoridated. One level above that are long-lasting, protective interventions: immunization, brief intervention for alcohol, cessation of tobacco smoking, colonoscopy.

One level above that are clinical interventions that require long-term, consistent care, such as treatment for high blood pressure and high cholesterol and diabetes. And one level above that are counseling and education interventions to encourage people to eat healthier or be physically active.

In general, the lower you are on that pyramid, the more effective your intervention. But every level of that pyramid will be potentially essential and important to address different health problems. There are some problems for which we only have counseling and interventions, and therefore we have to emphasize them.

By making communities healthier, prevention can be a best-buy. It can increase the health value we get for our health dollars. It can reduce the per-capita annual health-care costs. And the Affordable Care Act expands the coverage for preventive care, increases funding for prevention, and supports the public health infrastructure.

The most important means to improve health within the clinical context are what I call the ABCS – aspirin, blood pressure, cholesterol, and smoking. A-B-C-S. And on the ABCS, the USA gets an F, currently. Of everyone for increased risk for heart disease, the proportion on an aspirin a day is 33 percent. Of everyone with high blood pressure, the proportion who have it under control is 45 percent; of everyone with high cholesterol, it’s 29 percent; of all the smokers who try to quit, only 20 percent get help – in fact, only 2 percent get medications, which would double or triple their likelihood of succeeding in becoming tobacco-free.

That’s despite spending one out of every six dollars of our entire economy on health care. It would be difficult to spend this much money and do worse at the most important things we need to do.

There are, I believe, in both the community sphere and the clinical sphere key winnable battles, things we can make a big difference in, but they’re not going to be easy. I want to discuss very briefly six of them: tobacco, obesity, health-care-associated infections, motor vehicle injury prevention, teen pregnancy prevention, and HIV prevention.

Tobacco remains the leading cause of preventable death in this country. Today, more than 1,000 Americans will be killed by cigarettes; 440,000 this year. These are some simple statistics: States get about $25 billion a year from tobacco taxation and the [Tobacco] Master Settlement Agreement. Tobacco companies spend about half that – about $12 billion a year – on marketing and promotion. The Centers for Disease Control recommends that states spend nearly $4 billion a year, which would be about a sixth of what they take in from tobacco taxes and the settlement agreement. But they actually spend only about $700 million a year, and that number is falling fast, with budget cuts around the country. We’re not spending where we can save the most lives.

In California, the California Tobacco Control Program has not only saved lives dramatically but has saved money. Current estimate: $10 billion by 2004 in expenditures that didn’t happen because patients didn’t get diseases that required expensive care. Often we spend a lot of effort thinking about how we can shave dollars out of health care encounters. But wouldn’t it be better if that encounter didn’t have to happen in the first place?

There are enormous medical and societal costs to obesity. It costs our society about $150 billion a year. Obesity accounts for about a quarter of all medical inflation over the past 10 to 15 years, and someone who is obese will cost on average about $1,400 more per year to care for. But there are enormous health consequences that may not be widely understood. There are associations with asthma, sleep apnea, liver disease, infertility, arthritis, gout, cancer, pancreatitis, diabetes, hypertension, stroke, cataracts and many other health problems.

Just as policy has been the driving way to change the [prevalence of] tobacco use in society, policies are going to be the most effective way to reverse the obesity epidemic. Price is likely going to be the most important intervention, but whether it is feasible to change it remains to be seen. Decreasing the costs of fruits, vegetables and water; increasing the costs of unhealthy foods. Image: restricting advertising to children of unhealthy foods, and on the other side, showing the human impact of nutritionally harmful beverages and foods. Access: increasing exposure to healthy foods and water, and decreasing exposure by making at least schools, health-care facilities and government institutions free of junk food, including sugar drinks.

Health-care-associated infections affect as many as one in 20 people who go into a hospital. They cost $30 billion a year just for hospital infections, and we don’t even have a handle on how common infections are in dialysis or nursing homes or ambulatory care centers, but we know there are significant problems there. They kill 100,000 people a year. Yet we can do much more by systematically tracking, by standardizing, by implementing evidence-based reporting guidelines and prevention guidelines, and by changing our reimbursement [policies]. In fact, earlier this year, CDC released the first report of standardized infection ratios showing an 18-percent reduction in one particular type of health-care-associated infection.

Motor vehicle injuries: 40,000 deaths, 4 million emergency department visits, economic impacts of more than $200 billion a year. It is the leading cause of death in young people and the second leading cause of preventable years of life lost in our society. One hundred percent seat belt use would save nationally 4,000 lives and more than $100 billion in costs. Reductions in impaired driving – at least a third of fatal motor vehicle injuries in crashes in California are in impaired drivers. Graduated driver’s licenses will save many lives and reduce injuries substantially. And there can be great transportation sector engagement between transport and other sectors to promote safety policies.

The teen birth rate has been rising or stabilizing after declining for many years. Two-thirds of pregnancies in teens are unintended. Teen pregnancy perpetuates a cycle of poverty; [it] is often the intergenerational transmission of poverty. It also costs taxpayers billions of dollars a year. There’s a lot that we can do by increasing access to long-acting reversible contraceptives, improving reimbursement policies, and working to change the social norm. California has made important progress here; 15 years ago, California’s teen pregnancy rate was above the national average [and] today it is below the national average.

HIV prevention: More than a million Americans are living with HIV, and as many as one out of five [of them] don’t know they are living with HIV. In San Francisco and in many other urban areas, we are seeing a resurgence in risky sexual behavior, which is manifesting first as an increase in syphilis cases and then as an increase in HIV in young men. Men who have sex with men are about 50 times more likely to be infected with HIV as other men. There’s a lot we can do, by increasing awareness of HIV status, improving linkage to care so that everyone who’s positive knows they’re positive, and everyone who’s positive is in care. Prevention with positives is very important, so that people can protect themselves and protect their partners and their communities. And expand prevention programs that reduce risky behaviors.

Condoms cost about a nickel when you buy them in bulk, and you can distribute them through government programs. The lifetime cost of treating one HIV-infected person is about $400,000, and in fact the entire societal cost is about $1 million, when you count productivity and other indirect costs. You can buy a lot of condoms for $400,000, and there’s no reason that any venue in this country where high-risk populations congregate, whether it’s a gay bar or another place, shouldn’t [have] an unlimited supply of condoms in all of those locations. It’s not going to ensure they’re used, but if they’re not there, they’re much less likely to be used.

Recent exciting evidence shows that when there’s a discordant couple use of anti-retroviral treatment reduces the risk of spread by about 90 percent. That’s very important, because it means that not only can treating someone help them live longer, but it can help their partner and blunt the spread of HIV.

Safer, healthier, longer lives are in all of our interests. We’re all connected by the air we breath, the food and water we consume, and the space we occupy. But an outbreak anywhere is a risk anywhere. Detecting and containing disease threats closer to where they emerge will save lives, both here and abroad.