Preventive Medicine Grand Rounds: The Prevention Paradox

LAURA SANDER: Welcome to our 2014 annual J. Douglas Colman lecture This is presented as part of the general preventive medicine residency program I’m Laura Sander, chief resident of the program We have over 600 alumni throughout the country and the world, in fact And this year we’re proud to be celebrating our 50th anniversary year here at the school The Colman lecture honors Mr. Colman, who helped launch the Associated Hospital Service of Baltimore, the city’s first nonprofit health service plan The plan presented a unique approach at the time, combining insurance and health care that promised health coverage to clients and payment for providers He charged $0.75 a month for the plan, which, I think, we would all agree would be quite a bargain on the exchanges today In time, his innovative approach to health care became a great success, eventually becoming Blue Cross Blue Shield of Maryland Mr. Colman was a lecturer at our school from 1947 to 1951, and then went on to become VP for Development at the Johns Hopkins Hospital J. Douglas Colman’s dear friend and president emeritus of the Johns Hopkins Hospital, Dr. Nelson, established this lectureship in 1974 to honor Mr. Colman Mr. Colman’s two daughters endowed the lectureship so that I can continue to inspire and inform those students, faculty, and those who work in public health about our field We’re very happy to have Miss Jane Lamont here today, one of Mr Colman’s daughters Thank you for being here Before I turn the podium over to Dean Sommer for the introduction, I’d like to review some of the logistics for the grand rounds today Following the presentation, we’ll have a question and answer period And I’ll ask everybody to come up to the microphones at each of the sides of the auditorium We also have a live webcast going on So we’ll be able to field questions from folks that are joining us online After the talk today, we invite everybody to find Stone Hall for reception with Dr. Fineberg And I’ll turn it over to Dean Sommer [APPLAUSE] ALFRED SOMMER: It is quite extraordinary when you think that Dr. Colman came here in 1932 to set up something that we’re still struggling with today So it’s a great honor and pleasure to introduce my long-time friend and colleague, Harvey Fineberg, as this year’s Colman lecturer At our age, we no longer refer to one another as old friends Harvey is one of those people for whom it can truthfully be said he needs no introduction Having obtained his bachelor’s, medical, master’s, and doctoral degrees from Harvard College, Harvard School of Medicine, and Harvard’s Kennedy School of Government, Doctor Fineberg quite literally bleeds crimson He is a leading scholar in medical decision-making and a master administrator As dean of the Harvard School of Public Health for 13 years, he was the quote, “senior dean” when I first became dean of this school and provided me with valuable advice and encouragement, a function he still performs on a regular basis Indeed, he was a major speaker in this very hall the night it was inaugurated, at which time Michael Bloomberg announced that a generous trustee, Skip Sheldon, who had provided funds for its construction, asked that it be named in my honor After serving as the Harvard School of Public Health’s dean for 13 years, Dr Fineberg assumed university-wide responsibilities as Harvard’s provost He left Harvard to take on the globally influential health leadership role of president of the Institute of Medicine, a position he will be departing later this year after having served a much heralded two terms We are indeed fortunate that Dr Fineberg, one of this country’s and the world’s most eminent health scholars, has joined us today to deliver the annual Colman lecture It’s always a pleasure to hear Harvey [APPLAUSE] HARVEY V. FINEBERG: Well, thank you, Dr. Sander And thank you, especially, Al, for that very warm

introduction It truly is a pleasure for me to be here with all of you And Al, I can only imagine how humbling it must be for you to stand beneath the portrait of your illustrious predecessors here in Sommer Hall It’s an exceptional tribute It’s so well-deserved and so much admired by everyone in the public health community It’s a treat to be with all of you and to talk about a subject that I’ve thought long and hard about as a member of the public health community We all believe in prevention It’s a core tenant of public health So my question to you is, why do you believe in prevention? [LAUGHTER] Al told you Is that why? No, that can’t be the whole reason Why? AUDIENCE: It’s better than cure HARVEY V. FINEBERG: It’s better than cure Why is it better than cure? Isn’t cure good? AUDIENCE: Quality of life HARVEY V. FINEBERG: Quality of life often better What’s that? Longer quality of life, if you prevent disease before it starts It’s easier Easier than cure? We’re going to talk about that [LAUGHTER] In principle, it’s easier What else? AUDIENCE: It’s often cheaper and less expensive HARVEY V. FINEBERG: It’s often cheaper and less expensive than cure Is that always the case, by the way? AUDIENCE: Not always HARVEY V. FINEBERG: Not always You have to actually look at the evidence, don’t you, sometimes? The point about prevention, we hold it as a deep and core tenet And it’s a lot of good reasons, some of which we’ve already elaborated But it’s an instrumental reason We care about prevention not for its own sake We care about prevention because it does these other things, because it keeps us healthier, because it may be easier, because it may be longer lasting, because it may be more cost effective All of these mays actually need to be tested But I’m not here to persuade you about the importance of prevention, because I know we all already believe in prevention Instead, I want to reflect with you on if it’s such an obviously good thing most all the time– why is it that we don’t do it more regularly, more consistently, more widely, more effectively? What’s stopping us? That’s what I want to talk about with you today and reflect on together What do we know about the difficulties? And what could we maybe come up with as ways to overcome some of those difficulties? But let’s begin by taking a step back This is a depiction of the trend in life expectancy at birth in the United States from the beginning to the end of the 20th century This is a figure that’s familiar to all of you who have sat through any of the basic descriptive epidemiology courses, which is all of you here What’s this all about? AUDIENCE: Well, it’s the flu or the First World War or the combination HARVEY V. FINEBERG: The great flu That was the great influenza following the First World War, 1918-19 That produced this abrupt and sudden decline What’s all this difference about between men and women? Well, if you can figure that out, there’s going to be a big prize for you somewhere But it’s so interesting, isn’t it, that it’s persistent It’s not just in the United States It’s worldwide It’s not just overall from birth It’s at every age So it’s a very, very interesting phenomena So there’s a lot to learn and to understand just from this amazing curve in a century Why do I say amazing? Because here in the space of one century, life expectancy at birth in the United States, and actually, in many other countries, went from under 50 years of age to more than 75 years of age So that’s like 25 years of life expectancy at birth in the space of 100 years

Or to put it another way, that’s like three months of life expectancy gain at birth for every year I mean, have you ever heard a better argument for birth control? Just wait another year, and a baby will have three months more of life expectancy [LAUGHTER] It’s pretty good Most of this improvement, most of the improvement, particularly in the first 2/3 of the century, pretty clearly attributable to vaccines– AUDIENCE: Clean water HARVEY V. FINEBERG: –water, clean water– AUDIENCE: Safe food HARVEY V. FINEBERG: –safe food, a little later, anti-microbials all of which do what? Helps prevent disease and its complications We’re not going to get into secondary prevention and tertiary prevention and thinking about, well, when you treat hypertension, is that treating blood pressure, or are you preventing the complications of hypertension But the key idea here is that prevention has made the most difference in our health over the last century So we all believe in it We all like it It’s evidence overwhelming that it’s important, that it matters, that it makes a difference So what is it about it that we’re not able to do it more regularly and more consistently? It’s worth taking a moment to just reflect on the differences between curative approaches and preventive approaches If you go to your doctor because you’re experiencing symptoms, and you’re trying to get help and relief, basically, the doctor’s goal is to figure out what’s causing the problem, what is known about it, how to treat it, what’s the pathology driving the illness, how do you interrupt that, and how do you either cure or treat and maintain and manage the patient So curative medicine is about starting with understanding the pathology of the disease Preventive approach, a population approach, is about identifying risk In a curative approach, you’re trying to get the individual patient back to their normal, back to their pre-disease condition In a preventive approach, your goal is to shift the whole population norm If you look at the ethos of curative care, it’s all about individual patients, one at a time We always talk about individual-centered health care, trying to meet the needs of that individual patient A public health perspective is about a responsibility to the whole population So it has a different frame of your principal responsibility And when you’re dealing with a treatment, typically, we’re talking about a clinical intervention, an intervention in something the doctor does, or prescribes, or manages on behalf of the patient When we’re talking about prevention, most of the time, we’re talking about a broad spectrum of interventions that go well beyond, but incorporate the clinic, into behavioral and social and other opportunities to prevent disease So we could elaborate on this But basically, the mindset for prevention is very different from the mindset for cure And we’re going to come back to that as we examine some of the reasons why prevention is celebrated in principle, but often under-used or resisted in practice So let’s review some of the reasons First, when you succeed in prevention, it’s invisible How many of you have not had a heart attack because you’ve been exercising, eating well, refraining from smoking? How many? How do you know? [LAUGHTER] Al, you can be sure But the rest of us can’t be sure We can be very confident on average, on average, that we do better But do we really know about our personal experience? Doesn’t everyone know an 88-year-old who smoked like a chimney all their adult life? What’s that all about? They didn’t get the heart attack either So if you’re going to administer HPV vaccine to a young woman and she doesn’t get cancer, does she

know it was because of the vaccine? She can’t know that Not everybody is going to get cancer So when prevention succeeds, it’s invisible We talked before about the importance of statistics and the challenge of biostatistics Statisticians count what occurs We don’t count what does not occur And the danger of being invisible is that it’s easy to be taken for granted And this is a big part of the underlying problem around resistance to vaccines that would prevent childhood ailments like measles and whooping cough, where parents have never known anyone who had measles So invisibility is one of the things that can make prevention a hard sell When it works, you can’t see it Secondly, a lack of drama Now, can you imagine a television series about prevention? I mean, think of the plotline Nothing happens [LAUGHTER] I mean, this is not exactly the emergency room It just wouldn’t work that well I mean, think about when a surgeon transplants a liver into a child and we celebrate the success of saving that life Rightly so Do we actually give much thought to the child who was in the automobile who was not in a child restraint seat, who was in an accident, and is the donor of that liver? We don’t think about that side because it’s not the visible drama that we are looking at when we see a success in health care So if you’re going to be successful in public health working on prevention, somehow you’ve got to be satisfied with a lack of drama Or make it up other ways, but it’s not going to come from prevention Third problem, prevention is all about statistical lives We alluded to that earlier when we talked about who didn’t have a heart attack, or who didn’t get cancer Prevention’s success is about statistics It’s not about individuals Now, I don’t know how many of you are old enough to remember when a little baby, three years old or so, fell down a well in Texas This was Baby Jessica You could probably look it up on the web And Baby Jessica riveted the nation’s attention I mean, there was 24/7 news coverage about the baby stuck in the well with the fire department working to dig in parallel to get the baby out And the baby was eventually rescued, and it was fantastic But was there any coverage to the millions of babies stuck in poverty that was equally constraining for them and their life chances as that little baby that was physically stuck in the well? When it comes to prevention and public health, every statistic is a number with a tear attached to it But we don’t recognize the individuals We think about statistical lives And that makes it harder to make the case to others Now, prevention, intrinsically, may not express its benefits for a number of years You can live a rather unhealthy lifestyle and manage quite happily, thank you, for some length of time, and maybe for a long time But on average, it’ll catch up with you, but not for some years And by contrast, if you’re going to follow prevention, it will be a long time before the actual benefits accrue to you That’s one thing for your calculation It’s another thing for an insurer’s calculation who’s paying

And that’s the reality of the long delay before most of the benefits tend to arise There’s a wonderful experiment that was done with four-year-olds– and you can see the videos of these also– where the child is seated in a room And there’s one-way mirror, so you can see the child And the experimenter places a marshmallow on the table in front of the child And the experimenter says to the child, I’m going to go out I’ll be back in a couple of minutes And if you haven’t eaten that marshmallow, I’ll give you a second marshmallow And then the experimenter walks out of the room But, of course, the one-way mirror is there with the camera, and we’re watching the child And they are a riot Some of them gobble that marshmallow, like, in five seconds Some of them stare at the marshmallow They poke the marshmallow They writhe around the marshmallow They distract themselves And lo and behold, it turns out in follow-up that those children who are able to defer gratification at age four and wait for the second marshmallow actually tend to do better in later life What a predictive test that could be So I’m reminded of the patient who visits his doctor And the doctor says, you know, everything’s basically all right All you’ve got to do is take off 20 to 30 pounds, get 30 to 60 minutes of exercise every week, quit smoking, cut down on the drinking, and try to relax Get the stress out of your life The patient stares up at the doctor and says, can’t you operate? [LAUGHTER] We’re not so good at taking the long delay before the rewards appear And there’s a complication I mentioned the insurers and the payers Because of the long delays, the benefits that accrue to prevention may not actually reward the one who had to pay for it years earlier So this is a challenge in health care, especially when we’re thinking about the trade-off of curative and preventive services Just imagine for a moment that we were constituted as the board of a hospital And one of the staff comes to us Maybe her name is Dr. Sander And she says, I’ve got a wonderful proposal We have 188 admissions every three months for complications of diabetes They’re all in our community If we mounted a community-based, nurse-centered intervention program, taking care of people in their homes, out of our hospital, we could keep 1/3 of those people at least out of the hospital and maybe a half And the cost would be less than what it costs us to care for 10 of those patients Well, that sounds pretty good And then somebody says, well, let me understand this You want us to advance the money for this community-based program Yes And as a result, we’re going to keep people from coming to our hospital Yes So we’re going to have fewer patient days on our hospital? Yes Well, about that time, one of us on the board is bound to raise the question of whether this is really the business of the hospital to get involved in community-based intervention Because after all, there are public health people to do that And maybe our job is to take the best care of our patients exactly what they need and then get them back out Well, the problem here, in that instance, is that the payer and the beneficiary aren’t aligned And that distortion can lead to other distortions about what looks like a preferred or a less preferred approach to solving the problem OK We’re not consistent

Just ask me about butter Ask me about salt. Ask me about mammography Ask me about screening for prostate cancer Anybody want to ask? [LAUGHTER] Well, you should’ve asked either one month, three months, six months, or 24 months ago if you wanted my old answer So what happened when the Preventive Services Task Force looked hard at the data about mammography screening? They found that screening, which is a form of prevention, isn’t always without any associated risk In fact, the false positives in the screening tests can lead to not only anxiety, but needless intervention, additional cost, and some risk to the patient And they looked at the trade-offs in the population who did not have additional risk factors And they came back with a recommendation that if you’re under age 50, really, you should consult with your physician and decide on an individual basis whether these risks are worth, to you, the potential benefit of mammography That turned out to be a rather complicated message And it was not interpreted very accurately or aptly very often in the coverage that followed So prevention isn’t always an all-or-none thing based on the evidence There are some subtleties There are some differences Einstein told us, make everything as simple as possible and no simpler So with prevention, we do have to follow the evidence But the inconsistency, the changeability, of evidence over time, even when it’s based on re-analysis of additional or good data– never mind when it’s based on just the latest particular study, which isn’t exactly enough to change your mind When it’s based on real evidence, it’s confusing to the public And we have to recognize that changeability and variation is a part of the problem of getting people to believe in taking action about prevention Did anyone here see the Woody Allen movie, “Sleeper”? ’73? Some of us are dating ourselves But we did We loved it And you remember when the capsule opens, and after, whatever, 100 years, the occupant emerges and asks for some something like bamboo shoots or some very healthy kind of stuff? And they look at each other and say oh, yeah, that’s when we thought steak and butter were bad for you So even Woody Allen has picked up on the changeability of advice How to give advice which is honest and adherent to the exact evidence, how to make it understandable, and communicate it, and convey it, and how to interpret new evidence is a continuing challenge to make prevention more usable and to make it more acceptable We’ve talked a little bit about this idea already Prevention often doesn’t work from a one-time intervention Some vaccines, yes But if you’re going to control your blood pressure, if you’re going to watch your diet, if you’re going to follow exercise, if you’re going to refrain from smoking, that is a daily, hourly, every day, every day of the week activity Mark Twain once remarked that it’s easy to quit smoking He’s done it hundreds of times [LAUGHTER] After he finished every cigar So persistence and making it last is really a tricky part of making prevention work Now, here’s one that I think is often underappreciated and, I believe, is quite provocative So I want to ask you a question

Imagine, for a moment, that you are in charge of an island population on a Pacific archipelago And it turns out that there’s a new influenza that has broken out and is advancing island-by-island toward your home and your people Everywhere that this influenza has struck, 50% of the people have died It’s a very serious flu Fortunately, there is a new vaccine, which is just becoming available just in time It appears that this vaccine is 100% protective However, the vaccine itself produces 10% mortality Are you with me on the premise? You’re in charge The flu is coming 50% die from the flu You have a vaccine But if you use the vaccine, 10% of the people will die Everybody clear on the question? OK, now, what would you do? How many of you would administer the vaccine? Raise your hands How many of you would not administer the vaccine? Oh, quite a few, including our lawyer, which I understand [LAUGHTER] Give it to another island HARVEY V. FINEBERG: Give it to another island Well, that’s nice [LAUGHTER] AUDIENCE: [INAUDIBLE] HARVEY V. FINEBERG: Oh, yeah, well, we can talk about variations on the theme here But for those of you– most of you, actually, I think, were willing to administer the vaccine I would say 3-1 ratio But what if the mortality was not 10%? What if it was actually 20%? How many would still administer the vaccine if one in five died from the vaccine? Nobody? Oh, a couple More than a few OK, you’re just a little slow on the pickup here OK, 20% Would you go up to 30%? Making you uncomfortable at 30% OK, so for some of us, we weren’t going to use this vaccine even it was 10% But most of us were And then about half of us are still willing to use it when it gets up to 20% And maybe some for 30% And I’ll bet– what if I said 1/3 die from the vaccine, half die from the disease Anybody willing to use the vaccine? Anybody? A couple A couple hardy souls who haven’t taken law yet So oh! Silly me I actually got it backwards The flu has killed 10% of the people And the vaccine kills 50% Really, I mean, I’m sorry I just misstated How many people now want to use the vaccine? Anybody? OK, now here’s my real question Why was this a hard question when the flu killed 50% and the vaccine killed 10%, and a trivially easy question when the flu killed 10% and the vaccine killed 50%? What’s going on? Why does it matter? What if I just said Cause A, Cause B, green and blue, red, and white? Does it matter? Well, when you think about it, it kind of does matter to us Maybe some of us would want to force ourselves to decide as if there’s no difference I might have been able to push this gentleman to 49, 50, I betcha, because he was up at 30%, was still ready to go with the vaccine Is that true? [LAUGHTER] Pretty much, yeah OK So it turns out for most people, when it comes to prevention, we have a bias against errors of commission We don’t want our act to be responsible for harm And we’re not indifferent as to whether it’s natural or whether it’s something we produced by acting Now, some theorists will tell you, inaction, when you could act, is morally identical to action There’s no real moral difference Some would say, well, yeah, there is a difference

And there’s even a difference in the law But should there be? It turns out, very interestingly, going back to cure as opposed to prevention, that for many cases of treatment and diagnosis, we have exactly the opposite bias We have a bias against errors of omission We want to do every test We want to make sure we haven’t overlooked any possibility And the essential difference, I believe, is where is the default starting point In the case of the threatened flu pandemic, the default starting point is that the people are well The flu hasn’t struck And if we intervene, it’s our act that made them worse And in the clinic, the default starting point is the patient is ill and not getting better And if we fail to act, the patient is not going to do well I when it comes to prevention, most of us have a bias against errors of commission And I think it’s a very reasonable question– is this what we want, to act as if? Or do we want to be aware of it, and guard against it? Maybe we’ll come back to that Here’s another problem with prevention Oftentimes, in society, we tend to accept avoidable harm as normal So we think it’s just normal that people occasionally get shot It’s normal It happens in Washington, DC It even happens in Baltimore It happens in cities all over the United States It happens in the United States quite a lot more than in any other country in the world But it just happens It’s normal It’s normal that occasionally people go berserk and shoot their friends and others in the way, much less people they despise That’s normal We tend to accept as normal what is actually preventable What’s the right number, from a public health point of view, of murders in our community? The right number is zero That’s the right number That’s the quote, “desired norm.” But we accept what there is as normal We used to accept that parents would beat their children That was normal When we accept as normal things which are harmful and preventable, it is an added obstacle to making them work Now, we are talking a lot about the comparison of prevention and treatment One of the most telling differences is what do we expect when we evaluate a treatment as compared to what we expect when we evaluate a preventive When it comes to a new treatment, a new technology, an intervention, what we ask of that technology typically is that it produce benefits that are worth the costs We know it’s going to cost something, but we want the benefits to outweigh those costs That’s the standard that we apply when it comes to treatment When it comes to a preventive, perhaps we’ve been spoiled by the success of vaccines, which, by some measures, childhood vaccines actually produce $8 of net savings for every dollar invested in administering the vaccine So when it comes to a preventive, we don’t want it just to be worth the cost We want it to produce net savings And that’s a double standard That’s supplying a different and higher requirement to make a preventive acceptable than it is for a typical treatment This one is pretty obvious, commercial conflicts of interests I don’t know how many of you happened to have your TVs on back in the 1990s when there was a film, video of the CEOs of major tobacco companies testifying before the Congress

about the harmful effects of tobacco smoke And they were asked one after another whether they believed tobacco was addictive And one after another, each of them testified no, no, no Right down the line, all seven major tobacco CEOs Not one of them affirmed that they allowed that tobacco could be addictive Now, maybe it’s the case that if you happen to be the CEO of a major tobacco company, in your heart of hearts, you might believe that nicotine is not addictive Human psychology being as adaptive as it is could produce that honest response imaginably But that doesn’t mean the rest of us should be victim of the delusion of those holding commercial interests And so when very strong commercial interests are at stake, whether it’s tobacco or any other industry, it can be very distorting as to the virtues and importance of taking a preventive approach It’s only necessary sometimes to elevate doubt in the minds of the public That’s enough to forestall public action And finally, it’s not always commercial interests that conflict It may be personal, or religious, or cultural norms and convictions There are many people in these United States who believe it is their God-given right to ride their motorcycle without a helmet Free, they are free And there are some people who still believe it’s immoral to use condoms, even for the purpose of preventing disease And there are those who absolutely believe in faith healing and won’t have anything to do with vaccines or any other intervention in medicine So deep cultural beliefs can run against prevention in the same way that they may at times run in favor of prevention And we’ll be talking about that in just a moment But in making this transition, it’s very important to think about where do these beliefs and convictions come from, and what is it that makes people want to do something or not want to do something One of the great gurus of advertising of the last century was a fellow named Tony Schwartz, who specialized mainly in radio and auditory advertising, but he also did some television ads In fact, those of you old enough to remember the Johnson-Goldwater campaign will never forget the ad with the daisy and the atomic bomb Do you remember that little girl counting down the petals of the daisy? Turns out that ran once on commercial television It’s been shown hundreds of times subsequently because it’s such an iconic ad That was Tony Schwartz’s ad It was Tony Schwartz who produced the ad that actually drove tobacco advertising off of television You know, when tobacco was first being restricted on television, it wasn’t forbidden to advertise tobacco What was required was that the station had to run an equal number of anti-tobacco ads And these were the days of one-minute advertisements And Mr. Schwartz produced an ad which had two children standing in the closet talking baby talk to one another, trying on their parents clothes And mostly, you saw their feet and the dresses and the big hats and the high heels that they were stepping in It was adorable And this goes on for, like, 52 seconds And then in the last eight seconds, there’s a voiceover And it says something like, children love to imitate their parents Do you have children? Do you smoke? That was the whole ad But it sent chills up and down your spine And that was enough to drive tobacco ads off of television Now, what Tony Schwartz taught is that the purpose of an ad was never to communicate new information into the mind of the listener or the video or the viewer The purpose of the ad was to elicit

from the inside of that individual what they already knew and believed, but hadn’t connected to the particular product or purpose that you’re making the ad to demonstrate And that’s a pretty significant lesson, I think, for those of us in public health in thinking about how do we connect the messages of prevention to the interests and awareness and knowledge already of our listeners Now, what are some ways that we can try to overcome these dozen and more obstacles? I’m sure if we went around the room, we could identify yet more difficulties But we’ve had a lot of those already What are some ways that we can overcome it? One of the best elements of the health care reform is the payment for preventive services, a very important innovation, because it puts prevention on a par, from a clinical resource point of view, with treatment And being able to get the preventive without a payment is a very important elimination of a potential obstacle But we can do more We can actually make some preventives cheaper than free What I mean by that are positive financial and other incentives to take up the preventive services There’s a very interesting program in Mexico, you may know about, Seguro Popular, which has as a part of the program the idea of encouraging low-income families who are supported by the program to receive regular check-ups, get the children vaccinated, and take other preventive measures And by doing so, they are rewarded with cash transfers It’s making prevention cheaper than free We spend a lot of time at work And employment and the places of employment, including universities, are in a prime opportunity to make significant influence on our ability to prevent disease A lot of times, employers have viewed exercise benefits as part of the package of benefits to an employee But increasingly, the evidence is clearer that such benefits are also an investment in the success of the employee in doing their jobs, the so-called presenteeism problem in which you’re there, but not really productive And the ability of many companies, leaders such as Johnson & Johnson, that have demonstrated worksite promotion for themselves and for others who have demonstrated the cost effectiveness of these interventions are a really important model for helping overcome some of these obstacles by making it easier to do what we should do in the workplace Reengineering, so that it doesn’t require us to take action, is a really important principle for increasing the effectiveness and the reach of preventives Think about automobile safety Yes, it’s true we have to put on our seat belts still, but the airbag is automatic The elevation of the rear braking lights to a line of visibility to reduce rear-end collisions, that’s automatic The ability to have protective barriers that reduce the severity, should there be a collision, that’s an automatic Thinking about how we re-engineer all aspects of our life, including basic ideas like making vaccines single dose, not requiring refrigeration, field available, and thereby, more easily used for prevention through engineering, so making the preventive more available, less costly, more accessible is a very important way to help overcome some of these barriers Using policy to help make the right choices easier is probably something that hardly needs to be raised in the Bloomberg Johns Hopkins School of Public Health, because Mayor Bloomberg in New York City was an almost ideal example of the political leader who took steps where possible to improve the ability of people

to make the right choices more easily You don’t have to choose about whether that trans fats are or are not going to be in your food, because the trans fats are eliminated You don’t have to make a choice about where you are or are not exposed to secondhand smoke, because smoking in all of the buildings is eliminated It was estimated that in five years, the frequency of smokers in New York City declined by more than 11% And there’s no doubt there are tens of thousands of people walking around New York– they may not know who they are– who would not be here if it had not been for these preventive measures It’s a wonderful story When Tom Frieden, who was then commissioner of health before he became head of the CDC, was coming to the mayor with his first proposal about eliminating smoking in the public buildings, and he had prepared– and it was really the element of the proposal to eliminate smoking in restaurants and bars that raised a lot of concerns I mean, people at the time were saying, folks will travel to New Jersey to get a drink They’re just not going to use our bars because they can’t smoke And so Tom was ready with a whole stack of arguments and reasons and evidence about why this would likely succeed So he has his meeting with the mayor He sits down The mayor says, what’s the purpose? And Tom says, I have a proposal that we eliminate smoking in bars and restaurants And the mayor said, are you sure it will save lives? And Tom said, yes And the mayor said, then do it And Tom said, but Mr. Mayor, this is a complicated problem There’s a lot of opposition– and the mayor cut him off And he said to Tom what I will now share with you, that the first lesson of salesmanship is that once you take the order, leave [LAUGHTER] Well, it’s not enough to count on leaders like Mayor Bloomberg All of us in public health are going to have to be more adept, more successful, more committed to reaching people strategically in multiple ways, direct communication, to be sure, the old-fashioned discussions, but also traditional media, and most emphatically, the new media, in reaching out to people to make prevention the norm, to make prevention part of a culture of health, to make healthy choices in our lives the choices that are the natural choices, the ones that you don’t have to think about before you do And my definition of a culture of health is when it’s a choice without a decision It’s just the natural, easy, obvious way to live your life And when we have gotten to that point, then we can honestly say we’ve overcome these obstacles and we have made prevention not simply celebrated in principle, but effective in practice Thank you all very much [APPLAUSE] Sure LAURA SANDER: Hi Hello? Here we are Thank you so much, Dr. Fineberg And everybody can make their way to the microphone there And then I’ll place this microphone over there for questions And as you do so, I wanted to thank you again for such a wonderful outline of the challenges that face us and some important ways to overcome those obstacles I wanted to lead off by asking you, given that the climate and the Affordable Care Act, where do you think we should begin focusing our efforts to get prevention on the agenda? HARVEY V. FINEBERG: The Affordable Care Act is a really important step forward for prevention, as it is for treatment But it is not a solution to all of these obstacles I believe that, for those of us in public health,

we do need to take all the action we can to mobilize the clinical facilities and bring together public health and particularly primary care so that prevention becomes not just without co-payment, but a regular, intrinsic part of clinical practice in an easy and natural continuity And I also think that’s not a substitute for all the other things that we are concerned with the public health, with population health Need to be working on in our schools, in our workplaces, through the media, reaching people in the community So clinical care altogether is an important asset for prevention But it’s really always only just a small part of the total picture Yes, sir AUDIENCE: Dr. Fineberg, fantastic talk Thanks very much You pointed out the double standard in evaluating treatment versus preventive services And there’s also obviously the issue of the degree to which prevention science is funded through for federal health research and development funding So the NIH receives 90% of the annual federal health R&D budget And by its own estimates, it spends about 20% on prevention And that proportion has stayed relatively constant over the last 10 years There’s a recent paper that showed NIH spending by disease condition hasn’t changed in the last 15 years, and that based on the burden of disease, there’s still substantial overfunding for infectious diseases compared to a number of chronic non-communicable diseases Can you speak to this aspect of prevention and what sort of advocacy is necessary, both internally and externally to the NIH, to perhaps start changing the way in which federal funding is allocated to prevention? HARVEY V. FINEBERG: That’s a very good and a very complicated question, that when we talk about priorities for research and allocation, it’s about much more than just prevention It covers the whole spectrum of purpose and focus of research and is a very deep and important topic With respect to the aspect about prevention, I would say first, that the responsibility of those of us in the prevention research community is to demonstrate the success of what we have done and the caliber of the ideas that we are putting forward for the future I personally think we’ve got to be ready to move beyond the traditional, very costly, very long-term large cohort model, which is the standard that we still tend to think about when we are thinking about discovery of prevention We need to be more creative also, not to abandon traditional modes of research, but to complement and supplement and augment them with lines of work that, for example, could take advantage of contemporary data systems that report and experience where patients are, new strategies that can combine preventive and clinical care For example, there’s a wonderful technology developed by a startup company in Wisconsin around asthma And the technology is remarkably simple in concept It’s a GPS-based monitor attached to an inhaler And what’s the purpose? It means that when you use your inhaler, the fact it’s used, by whom, exactly where, and exactly when are all available on data Now, you can track any individual’s pattern and see when they may be getting in trouble and approach an intervention But even more than that, you have an opportunity to scan a whole community’s use and to identify where there may be precipitating risk factors geographically located So being creative about the nature of the research that we can do, I think, is an important part of the selling Most fundamentally though, in response to the question of where do we focus, I believe that we have to start with the Congress, not with the officials at NIH It’s the Congress that allocates the money It’s the Congress that distributes and decides what has to be done with that money And the big issue, I think, is not within every institute, although those are issues I think the big problem is getting a sufficient, compelling, and very, very actionable case

on policy to put resources where prevention will do the most good And that’s where I would start AUDIENCE: Thank you HARVEY V. FINEBERG: Thank you Yes, sir AUDIENCE: As Yogi Berra said, [INAUDIBLE], it’s about the future And that was one of your comments But one of the concerns that I have– we had a conference here on gun violence And Mayor Bloomberg was here And none of the speakers or anything raised what I think is a fundamental issue, and that is we have to change the Constitution The Second Amendment and the courts seem to be the enemy of public health And is there any– am I wrong in this Or is there any movement or any ability? We’ve changed the Constitution before We’ve gotten rid of slavery We’ve got women’s rights, et cetera Why can’t we get rid of the Second Amendment? HARVEY V. FINEBERG: Well, politically, you can get rid of it There’s a process It involves 2/3 of the states over a long period of time But it’s not easy And it’s a very long-term process AUDIENCE: Do you think it’s necessary? HARVEY V. FINEBERG: Do I think it’s necessary? I will say this I hope not I hope it’s not necessary because I would hate to rely only on that solution to the problem of gun violence in the United States I think there’s a great deal we can do In fact, one of the studies that the Institute of Medicine took up with the request of the Centers for Disease Control was to develop a set of priority topics for gun safety and reducing handgun violence as research subjects And there’s a lot that we can do around even making the guns we have safer So I think there’s a great deal short of a constitutional amendment I was joking the other day with a group in Canada that as an American visiting– a Canadian, to me, is just an unarmed American with health insurance [LAUGHTER] So you know, they’re pretty basic But it’s not that different Canadians actually have a lot of guns in the homes They just don’t shoot each other as often And that’s a really fundamental issue for us in this nation And I think there are definitely things we can do short of a constitutional amendment AUDIENCE: But if you add to that either courts saying that you could carry guns anywhere, it’s really disturbing And they cite the amendment, the Second Amendment right HARVEY V. FINEBERG: Well, it would be a very long, drawn out, difficult, challenging change to the amendment But it would be a solution But I don’t personally believe that it’s a likely solution Yes, ma’am AUDIENCE: Thank you for your talk, Dr. Fineberg I do research on the cost of follow-up care after critical illness And one of my questions is, if you think about the costs of preventive care, so the cost of paying patients to come in for preventive care, for example, do you think that we can show that that saves the system money, number one And the second follow-up question is, do you think that we need to, or does that question matter, meaning should we be able to pay for preventive care, even if there’s not a follow-up savings HARVEY V. FINEBERG: On the first question, it’s an empirical question It’s a matter of study and proof I wouldn’t say that I have a firm conviction exactly A lot depends on the specific circumstances and conditions and terms and population, et cetera So could it? Yes, it could, in principle, save money But my main point is that I don’t believe that should be the necessary condition to demonstrate the value of doing it The value should come from convincing that the benefit achieved is worth what it does cost If it costs less than zero, well, that’s a great equation And it makes it infinitely good But if it costs something, that doesn’t mean we shouldn’t do it It simply means we have then to prove and demonstrate that the value of the benefit outweighs that cost Yes, sir AUDIENCE: First of all, thanks for this interesting talk I have maybe a hypothetical question If you happen to find the magic lamp, and you rub it, and the genie will come up, and saying you have two wishes I can achieve for you in regards to ways to overcome

the obstacles of prevention, what would be those two, one from your perspective as a physician, and the second from your perspective as head of an Institute of Medicine? [LAUGHTER] HARVEY V. FINEBERG: Yeah, it’s a really good question, especially toward the end of my term at the Institute of Medicine So two wishes to make this real My first wish would be that we gave prevention the priority it deserves in funding, in attention, and in incorporating into everything about practice and daily lives I’m not sure I’d differentiate my two positions to say which wish that applies to But if I had a second wish, it would be that we build together what I would describe as a culture of health in America Why shouldn’t Baltimore try to be the city in America where it’s the best place in the country to raise a child? What would that mean, if Baltimore were the best place in America to raise a child? Think about that What if Baltimore were the best place in America to grow old? What if Baltimore were the best place in America to have a healthy job and lifestyle? That’s the culture change that I’m dreaming about That’s what I would like to see happen AUDIENCE: Thank you HARVEY V. FINEBERG: Yes I guess this is our last question AUDIENCE: Yeah I’m a medical expert You’ve talked a lot about politicians And even just yesterday, President Obama kind of extended the CMS reduction in costs So it’s continuing to be a problem And I was wondering if you could talk a little bit more about who else needs to come to the table Because I think besides the Bloombergs and the politicians of the world, I think about insurance companies I even think about the lifestyle industry that’s outside of medicine Can you articulate a little bit more about who needs to come to the table to really make this happen? Because I don’t think you can have Baltimore as the place to raise a child solely on physicians and preventative researchers and politicians I think city planners– who else do you think needs to be in the conversation? HARVEY V. FINEBERG: There are lots of potential players and contributors that we could have at our table for prevention How many seats there are and how large the table really would depend quite a bit on exactly what are we talking about If it was about a healthy Baltimore, that would be one thing If it was about workplace health promotion, that could be a different mix But I think that the key idea for us in public health is to be mindful and open to all the relevant parties, those who have a stake, those who have an interest, those who have a contribution to make, and those who can be the beneficiaries In America, in policy, my feeling is it’s very, very hard to do a targeted harm for a broad collective good Because those who are harmed are going to resist like the dickens And those who are going to have a broad general benefit don’t care enough to get involved For public health, our mission is partly to energize the participants so they can appreciate how big a stake they have in the success of the prevention enterprise And if we can do that, maybe they’ll clamor to come to our table, and we won’t have to work so hard to bring them in AUDIENCE: Thanks HARVEY V. FINEBERG: I guess we have one more AUDIENCE: Well, actually, unintentionally, my question is a little bit of a follow-up Going back to your example about the vaccine and the flu, could you talk about, in those kinds of decisions, the role of the consumer, informed consent, and patient decision-making, which is a movement that is happening, and how that kind of fits into the dynamic HARVEY V. FINEBERG: The individual, the patient or the well person is the first line of action when it comes to health It’s your health It’s your family’s health You’re in control of a lot of the things that will make most of the difference for your well-being and for your family’s well-being So tending to inform, empower, engage, open opportunity for the public to be an active participant, active player, I think, is a really key part of the overall strategy to introduce a culture of health It’s not the whole story We have to bring the experts and the clinicians and the employers and government officials

But there’s no way to succeed without a central place for lay people, individuals, family, and community I think that’s a great note to end on Thank you very much [APPLAUSE] LAURA SANDER: Thank you very much