The US will devote 17.5% of GDP to health care this year, around $3 trillion. Yet only 3 percent of that will be spent on prevention, including both primary prevention (preventing illness in the first place) and secondary prevention (preventing sick people getting sicker or having a relapse). Medicine saves lives, doctors are heroes and the best earn Nobel prizes. Prevention, by contrast, is mundane, measurement of effectiveness is difficult, rewards and recognition pale by comparison.


In a recent NEJM paper, Tom Farley, Philadelphia Health Commissioner, bemoaned the underfunding of proven prevention programs while sick people certain to die nevertheless continue to receive expensive treatments. Why does a utilitarian greatest good for the greatest number perspective not prevail? Farley cites two reasons: when a life is at stake, it’s unethical to withhold treatment, regardless of cost effectiveness; second, medical treatments are funded by payers and providers whereas prevention programs are typically funded from public health budgets subject to annual budget cuts by short-sighted politicians.


There is another important reason. Diet, exercise and other lifestyle decisions are viewed by many as matters of personal choice, even though society may later have to pick up the health care costs associated with these decisions.  Prevention involves taking personal responsibility for one’s health. The worried well do so, wearing Fitbits or following diets, the chronically ill often do not.


Why do people not respond to good advice regarding diet and exercise? Continue reading