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June 18, 2007

Prevention, Allocation, & Health Policy

Alexandra Simotas, a reader and physician blogger over at the Houston Chronicle, has an interesting take regarding the recent bill Governor Perry (Texas) signed into law authorizing a state-funded cancer research institute.

Simotas writes,

It's obvious to me that we're feeding the slaughter houses!

How about funding the real solution? Prevention!

A slaughter house is a cancer institute that spends your money on research and experimental treatments and ignores the answer to its number one killer--eliminate tobacco and you eliminate lung cancer.

Slaughter house (definition from the Simotas dictionary) - fancy cancer institute where you drive up in a Porsche and you leave in a hearse!

Usually a slaughter house provides its victims (i.e., patients) with reading material such as fiction entitled "Living with Lung Cancer," versus non fiction entitled "Dying with Lung Cancer." 

Though I do not endorse all of the sentiments expressed here, the allocation of both private and public health expenditures in terms of health policy is a subject I have much interest in.  There seems little doubt that prevention, public health, and behavioral studies merit far less research dollars per capita (whether calibrated for public or private sponsorship) than clinical studies.  Though there are many reasons for this, an obvious one is that there are little rents to be captured in funding public health studies, as compared to studies evaluating the newest biologic or medical device.  Simply put, there's not much $$ to be made in public health, or at least not as much as there is in clinical practice.

Yet, at the same time, it seems difficult to contest that in the aggregate, public health practices have greater potential to positively impact health than clinical medicine.  I am not remotely suggesting clinical medicine is unimportant or lacks moral worth; my focus here is on the relative priority it is given in American (Western?) political culture.  If my surmise here is correct -- and it is, I think, generally if grudgingly accepted -- then the logical question is why our allocation decisions seem so weighted to acute care and novel biologics when mortality and morbidity could arguably be affected more by preventive care and public health practice.

I have some ideas about this, actually, but that's a whole series of blog posts.  I will say that much of this implicates a long-standing debate within public health revolving around the (in?)famous McKeown thesis, which denies any significant causal relation between declining mortality after 1770 and improved therapeutic or public health practices.  The McKeown thesis continues to generate substantial controversy in epidemiology and public health, and while most concede that clinical medicine had little impact on mortality prior to the mid-20th century, the role of public health policies regarding sanitation and sewage remains hotly disputed. 


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Interesting post. I'm taken aback (as I assume I'm supposed to be) by Simotas' statement: "eliminate tobacco and you eliminate lung cancer." Obviously that's factually incorrect, considering that many people have lung cancers which are not related to tobacco. It may seem like a "minor" point, considering that they are in fact in the minority, but people who suffer from mesothelioma and other such lung cancers suffer disproportionately when compared to other cancer patients because of the bias evident in Simotas' language.

But I guess that's missing the point, somewhat. I don't mean to say that money to research will save more lives than anti-tobacco campaigns. But to me Simotas' logic oversimplifies the problem a bit.


You're right to point out the overstatement, and I also suspect it is not at all a minor point. There's an excellent BMJ article regarding the stigma that lung cancer victims face because of the widespread view that their suffering is a result of their sins, even while 10% of such patients have never smoked.

What I found most interesting in the post was the larger point about preventive versus acute care, that we Americans allocate so much of our research and health care dollars into the newest biologics to use in rescue medicine, when morbidity and mortality would likely be reduced to a much greater extent on the aggregate if we allocated such monies to preventive and public health initiatives.

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