Blog | Monday, December 17, 2012

Forewarned is forearmed, except when it isn't

Those who don't learn from the follies of history, we are famously told, are destined to repeat them. One of the oft-repeated follies is to ignore vulnerability, and wind up dealing with the consequences of that neglect.

Our vulnerability arguably comes in two flavors. There's the kind we can't do much about except recover from it afterward. Perhaps earthquakes are an example of this kind, since we can do nothing to prevent them. Hurricanes may be an example as well, since they have long occurred with no help from us, although they are almost certainly getting help from us now.

But even hurricane damage can be pre-empted to some degree. The need for protective measures taken in New Orleans after Hurricane Katrina was well recognized before. Had such measures been taken in advance, the catastrophe would have been much diminished, if not averted. A similar case has been made about the calamitous effects of Hurricane Sandy along the Northeast coast.

And while we can't prevent earthquakes, we can build infrastructure to withstand them. So it may be the kind of vulnerability we can do nothing about doesn't really exist after all, or is very rare (as in, a-giant-asteroid-hurtling-toward-Earth rare). Most of the time, forewarned should be forearmed.

Which brings us to the other kind of vulnerability, the kind we can do much to alter. That kind prevails.

It may prevail with regard to monster storms, but that's not my field. So I can only repeat what I've heard experts say: Power lines could run in reinforced pipes underground, rather than between poles and among trees. Storm surges can be anticipated, confronted, and diverted in harbors and coastal lowlands. Such things are being done in parts of the world more inclined to look at vulnerability as an opportunity for self-defense than we seem to be.

Regardless of the causes of our severe weather, the consequences are clear to us all. It is penny wise and pound foolish to let infrastructure get destroyed and pay the costs of cleanup again and again, when better infrastructure would resist such destruction. But such investments need to be made before disaster strikes, and that's the dilemma.

It is a dilemma that bedevils the medical field, and particularly my specialty of preventive medicine, where I may rely on my own expertise and experience for insights. It is, in a word, silly to treat hundreds of thousands of myocardial infarctions annually while knowing how to eliminate almost all of them. Silly, and, of course, tragic.

It is silly and tragic to treat type 2 diabetes, formerly known as "adult-onset diabetes," not only in ever more adults, but ever more children while knowing how to prevent the condition in 90% of adults and eradicate it in children. After all, we invented type 2 diabetes in children within the span of just the past generation.

Prevention produces far better outcomes and costs less than treatment. But like hurricane-proof shorelines and earthquake-proof buildings, it requires up-front investments for returns over time. We tend to be bad at that. But we need to get better, because lives are at stake.

As may be the fate of the nation. The Centers for Disease Control and Prevention is projecting that by mid-century, should current trends persist, 1 in 3 American adults could have diabetes. Devastating though it is, the toll of Hurricane Sandy is small in comparison to this brewing storm.

The first message in these winds is that current trends cannot persist, because the dollar and human cost of that are apt to be unbearable. We currently have roughly 27 million diagnosed diabetics in the U.S., and struggle to pay the health care bill. When 1 in 3 of us has diabetes, that will be well over 100 million. There is no bank account big enough to write that check.

The second message may matter even more. Guess who those adults will be, burdened with more diabetes than the world has ever known? Our children and grandchildren. They will be the adults in 2050, dealing with the crushing burden of chronic disease we bequeathed them.

The trouble with even temporary neglect of vulnerability is that the longer you wait, the worse your options. At the individual level, if you address vulnerability after the onset of diabetes, or after a first heart attack or stroke, your health will simply never again be as good as it could have been. Chronic disease can be managed, but the adage about not being able to unscramble an egg applies to health. That's what Humpty Dumpty was supposed to teach us.

At the collective level, the more vulnerability converts to consequences, the more resources are diverted to deal with those consequences. Whatever search and rescue costs, we have no choice; the money must be spent. Whatever emergency angioplasty or coronary bypass costs, the money must be spent. The more often money is spent that way, the less likely allocations to prevention become because the money is already gone.

One tends not to hear any clamor for pinching pennies and shrinking government when it's time to send in the National Guard, bring helicopters into flood zones or over forest fires, or mobilize the Coast Guard for search and rescue. In contrast, in moments of calm and far better options, those voices gain volume. When there's time to make investments to prevent the next costly calamity, we are heeding the call to cut the deficit.

The trouble is that catastrophes are enormously expensive. Vulnerability to them is the quintessential case of a "pay now, or pay later" scenario in which the latter costs dwarf the former. Neglecting vulnerabilities we can fix is penny wise, pound foolish. The deficit grows.

When Ozymandias, king of kings, invited lesser sovereigns to look on his works and despair, he may have had intimidation in mind. But what is truly indelible is his vulnerability. As told most famously by Shelley, the kingdom of Ozymandias fell to ruin in the desert sand. We are misguided to think we are too mighty to do the same. Signs of our vulnerability abound.

The choice to take on vulnerability is never easy. Building a levee when the ground is dry may seem unnecessary, even frivolous. But of course, it's the only time to build a levee that will reliably prevent catastrophe, rather than one that might not be enough to mitigate it. Making a serious commitment to eating well and being active may not seem worth the effort or time before you are on your back staring at the roof of an ambulance or riding next to your child doing so. But afterward, the investment is larger and the return smaller.

We are vulnerable, and we know it. That knowledge is only power if we put it to use before the costs of that vulnerability come due. Forewarned is forearmed only if we take up the requisite arms against a sea of looming troubles, and by opposing, end them before ever they begin. Again.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.