Does "health promotion" really promote health?

American Journal of Economics and Sociology, The, Jan, 2005 by Alvan R. Feinstein

Like many other discussions of the government's role in "health promotion," Victor Fuchs' excellent paper (1) makes the assumption that "promotion" is a well-established entity, so that the main job now is to disseminate it to everyone, at reasonable cost. Since the history of medicine and public health contains many splendid triumphs that followed a long array of errors and blunders, it is always important, in any era of medicine, to consider the possibility that the establishment beliefs are not always correct. (2)

The idea of "promotion" is itself relatively new. Health and health care have always involved various forms of personal or societal interventions, but the idea of "promotion" usually refers to many new types of prevention, administered to apparently healthy people, that will help retain health and thwart illness. Until about 1920, preventive interventions were usually aimed at infectious diseases, and were given to society or individuals. The societal activities involved mainly sanitation, arranged in pertinent community settings, to remove or exclude bacterial contaminants from water, sewage, milk, meat, and other foods. The treatments given to individual persons were vaccinations against such diseases as smallpox and diphtheria.

These individual prophylactic treatments, which began late in the 19th century, were intended to prevent or delay the appearance of a target that has not yet occurred. The prophylactic treatments were a striking departure from the then-traditional medical practice of remedial therapy, which was intended to eliminate or ameliorate a target that already existed. Examples of remedial therapy are the use of an analgesic such as aspirin for headache, an antibiotic for infection, or blood transfusion for anemia.

I

Expanded Spectrum of "Prevention"

WITH THE SUCCESS OF sanitation and vaccination in the first quarter of the 20th century, attention was turned to other forms of prevention aimed at noninfectious or chronic diseases, such as cancer or cardiovascular disease. These activities, some of which became today's "health promotion," have vastly expanded the spectrum of prophylactic therapy for both individuals and society. Individually, prevention has been subclassified into primary, secondary, and tertiary activities. The primary activities include not only the old "one-shot" types of vaccination, but the short-term use of antibiotics in healthy persons, such as college students, to prevent the spread of small epidemics, such as meningitis.

Almost all other types of prophylaxis today involve daily or repeated long-term activities, often continued for life. In primary prophylaxis, individual healthy persons are encouraged to eliminate or reduce "risk factors" in diet, smoking, or physical sloth. Secondary prophylaxis involves efforts to reduce an asymptomatic physiologic abnormality, such as an elevated blood pressure or serum cholesterol, to prevent future diseases such as heart attacks or stroke. Tertiary prophylaxis, for diseases that already exist, is given with the hope of keeping them from getting worse. Thus, efforts are made to prevent recurrent attacks of asthma, rheumatic lever, epilepsy, or myocardial infarction. Whenever death is the outcome to be prevented, the treatment of cancer or coronary disease constitutes tertiary prophylaxis. A special new form of tertiary prophylaxis involves "screening." It is intended to find things like cancer in an "early" stage, and to treat it successfully before it spreads or does other harm.

Beyond these complex activities in prophylactic interventions for individuals, an expanded spectrum of prevention has developed for society. We now have the following public-health activities: campaigns against smoking, alcohol, and violence; efforts to prevent accidents, occupational injuries, and environmental pollution; procedures to improve maternal and child health; and tactics that bring greater safety to sex, contraception, and illicit use of intravenous needles.

These diverse activities in prophylaxis are all motivated by the old aphorism that "an ounce of prevention is worth a pound of cure." Prevention of disease certainly seems cheaper than having to give remedial therapy afterward. And everyone recognizes intuitively the unmeasurable individual value of remaining alive and healthy.

II

Problems Associated with Expanded "Prevention"

NEVERTHELESS, THE NEW ACTIVITIES in prevention have brought an array of problems in the altered ethos of the doctor-patient relationship, in medicalization of the public, in the enthusiastic advocacy of strategies that have not yet been fully evaluated or proved, and in costs of all the preventive activities.

In relationships with patients, doctors of the past used mainly remedial therapy in carrying out the old maxim that the physician's job is to cure occasionally, relieve often, and comfort always. This Samaritan role has often changed to something more like that of a nanny or scold, as doctors badger patients who otherwise feel well to change diet, exercise more, and take prophylactic medications more faithfully. A prominent objection to this approach came from H. L. Mencken, who said: "The problem with our society is the corruption of medicine by morality. The purpose of medicine is not to make men virtuous, but ... to rescue them from the consequences of their vices."