But while there is widespread agreement about the primacy of prevention in principle, divergent views arise as soon as discussion shifts to specific priorities, goals and methods of implementation. When the Obama-Biden Transition Health Policy Team offered three examples of preventive services in its guide for participants in Community Health Care Discussions (my college hosted one of the 8500-plus meetings held in December 2008), they skewed sharply toward a medicalized view of prevention, with early disease detection accorded the highest priority. The three examples were mammography, flu shots and cholesterol screenings.
Detecting disease early is, of course, far better than detecting it late. But the true holy grail of prevention is found not in detecting disease but in undertaking the lifestyle changes - whole foods diet, regular exercise, stress management and social support - that keep us well. There are clear indications that the Obama team recognizes the importance of these lifestyle changes. The key question is: will this recognition lead to a true paradigm shift, with large-scale increases in lifestyle-based primary prevention efforts backed by genuine budgetary muscle? Or will it amount to little more than lip service? In the coming months, generating support for broad-scale primary prevention through lifestyle changes must be among Americans' highest priorities.
It is worth noting that if every primary care medical physician in the nation delivered all preventive health services recommended for every patient by the U.S. Preventive Services Task Force, these physicians would have no time for anything else.1 No other patient care, no record keeping, no continuing education and no time for creative thinking. Therefore, simple mathematics dictates that either preventive services recommendations must be drastically scaled back (precisely the opposite of what policy analysts from left, right and center are proposing) or other delivery channels must be developed. Any meaningful prevention and health promotion plan must mobilize the efforts of other health providers (nurses, physician's assistants, chiropractors, naturopaths, acupuncturists and others) for these preventive services, consistent with their training and licensure. Like medical physicians, however, these other providers have additional responsibilities. Enlisting their help is necessary but far from sufficient.
A new prevention and health promotion infrastructure must be developed as well, along the lines of the Samueli Institute's superbly crafted Wellness Initiative for the Nation (WIN), which proposes implementation of new policies to "establish standards in comprehensive lifestyle and integrated health care approaches, and train individuals with qualifications to focus full-time on prevention." A new cadre of Health and Wellness Coaches is envisioned to fill the gaping holes in our current prevention and health promotion infrastructure. Also included in the WIN model are "specialist certification for health professionals in prevention, health and wellness delivery in specific settings and populations - for example, schools, worksites, the military, health care settings, and long-term care facilities," and creating "a Health Corps to provide an army of young and older people that would learn and model wellness behavior and support delivery of wellness education and training by the coaches." The current draft of WIN - at www.siib.org - should be read by everyone seeking to understand the transformative potential of the health reform moment.