Today I spend a few minutes on the topic of prevention, to which I have devoted my entire professional career.

Early on, it became abundantly clear to me that I could have a more significant impact preventing many of the problems that presented themselves in my office than chasing after them with treatments that did nothing, after all, to prevent them. Americans are not strangers to successful disease prevention. Over the past century, death rates in the United States from malaria, cholera, TB (tuberculosis), scurvy, pellagra, and typhoid, not to mention scarlet fever and rheumatic heart disease, have all plummeted. Illness and injury generally fall into a few major categories: microbial infections, nutritional deficiencies, toxins, and traumatic accidents.

Infections include diseases such as malaria, cholera, polio, TB, smallpox, scarlet fever and rheumatic heart disease, mumps, measles. There are a great many more. Malaria, which, like yellow fever, is caused by a parasite carried by infected mosquitoes, has been managed with mosquito prevention strategies. Cholera, like many other diseases that are transmitted by contaminated food or water, has been virtually eradicated with widespread modern sewage treatment. Some of the diseases in this list are seen so rarely anymore that their names are recognizable only through immunization schedules. I myself have never diagnosed a case of measles. I cannot say I have never seen a case; I may have but, if so, I unfortunately did not recognize it as such. This is not surprising: Unlike most doctors who practiced in the first half of the 20th century, my colleagues and I have little or no experience diagnosing measles.

Nutritional deficiencies often present with markedly complex and seemingly unrelated symptoms. Pellagra, caused by a deficiency of niacin (Vitamin B3), can present with a variety of symptoms ranging from insomnia to hair loss to diarrhea, dementia, and dermatitis, an inflammatory skin condition. We are coming, finally, to understand how the paired obesity and diabetes epidemics (along with all their associated chronic diseases) have been caused by a diet consisting largely of processed, nutritionally deficient items paired with a relative deficiency of whole, nutritious foods.

Scurvy, which can present with bleeding gums, wounds that don’t heal, or generalized weakness, is caused by a deficiency of Vitamin C. It used to be common among sailors who spent many months at sea surviving on biscuits and jerky, and far from fresh fruits and vegetables. Luckily, it is easily reversed with increased intake of citrus, such as an orange or a glass of lemonade. Believe it or not, I did actually diagnose, in suburban Cleveland, Ohio, in the 21st century, a simple case of scurvy, whereupon a previously chronic elbow wound healed in a week, just like that.

Preventing problems is not always simple, however. It can be tricky, with important and unforeseen consequences. Mandated use of bike helmets, for example, has markedly reduced the number of head injuries over the past 20 years. And while we all agree that this is a good thing, the fact is that among the initial effects of bike helmet laws must be included decreased income for those trauma centers in which large numbers of these sometimes gruesome injuries were previously treated. Nevertheless, we have pursued adoption of bike helmet laws across the country, not only because it is clear that the lifetime costs of caring for an individual with a devastating head injury far exceed the savings associated with preventing one visit to an emergency department.

We have become a bike-helmet-wearing nation because 1) we recognize that the price a family (and their community) pays for a debilitating head injury is unacceptable, and 2) we have the knowledge and ability to prevent a great many of those injuries. 

Preventing illness turns out to be not only a more humane way to practice medicine but a more economical way as well. To put most of our effort into treatment is to avert our eyes from what we know.