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  • Writer's pictureNick Allen

Shifting towards proactive healthcare

Medical care only accounts for a small fraction of a person’s overall health, and there are a few reasons why this is the case. For one, social determinants of health are both immensely important and largely unaddressed in the United States. Additionally, it is common practice to wait until symptoms arise to visit with a medical provider. This is problematic because we know that the primary path to longevity is delaying the onset of disease, not delaying mortality once diagnosed with a disease. Thus, the path of least resistance to living longer and better lives may not be advancing treatments (still important), but rather getting out in front of disease.

It is important to clarify that this line of thinking is primarily applicable to chronic diseases such as heart disease, diabetes, cancer, and neurodegenerative diseases. This limitation isn't a significant one, however, as chronic diseases are the main killers in our society. The four I mentioned are directly responsible for over half of all deaths in the United States, and contribute in some form to many beyond that.

Let’s first consider heart disease, the single greatest cause of death in the United States. It is exceedingly rare for someone to visit a cardiologist or discuss heart disease with their primary care provider without some sort of provocation. Usually this is chest pain, shortness of breath, or something along those lines. Occasionally, it isn't until a severe event like a heart attack that patients start meeting with a specialist. In the framework I’ve put together (Figure 1), someone with heart disease significant enough to cause chest pain is already in the stage of symptomatic disease. At this point, doctors can alleviate symptoms and minimize risk of disease complications, but generally can’t reverse the damage completely.

Figure 1: Disease progression and methods of intervention. Current approaches focus on eliminating symptoms and “buying more time.” Rarely do they truly cure a condition, and this incomplete treatment enables repeated passes along the yellow arrow, where irreversible damage is being done to body systems. A proactive approach would aim to both slow progression along the green arrow and reverse the first signs of disease.

To be very clear, this is a structural issue rather than a technological one. We already have adequate tools to identify heart disease risk factors and to put a person on a better track. Additionally, many of the same medicines we use to treat heart disease after symptoms appear are far more effective when started earlier. The problem is not our technology but our perspective, which is that disease does not need to be treated until it starts interfering with our lives.

This model is applicable beyond heart disease. Diabetes is perhaps an even better example of the potential of proactive healthcare. Hemoglobin A1c is a measure used to diagnose diabetes, and most people are not remotely concerned about developing the condition until their A1C is abnormally high. The problem is that, by the time your A1C is elevated, you are quite far along the diabetes progression (at or around the “symptomatic disease” stage in the diagram). At this point it is immensely difficult to reverse, whereas we have simple blood tests that could have picked up on signs of concern years before the A1C began to rise.

Again, this simply comes down to a need for a paradigm shift in the way we think of disease. Prevention is less tangible than treatment, even if that treatment simply alleviates symptoms. We are willing to fork over millions of dollars to extend life by a couple months (yes, this actually happens) because the need is urgent and visible. We often shy away from much more affordable and impactful early interventions, however, because the consequences aren’t immediately apparent. Nonetheless, these consequences are certainly present. They are avoidable, but escaping them will require a coordinated effort from providers, patients, and payers that has yet to arise.


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