An Ounce of Prevention....

“You and a friend are having a picnic by the side of a river. Suddenly you hear a shout from the direction of the water—a child is drowning. Without thinking, you both dive in, grab the child, and swim to shore. Before you can recover, you hear another child cry for help. You and your friend jump back in the river to rescue her as well. Then another struggling child drifts into sight… and another… and another. The two of you can barely keep up. Suddenly, you see your friend wading out of the water, seeming to leave you alone. ‘Where are you going?’ you demand. Your friend answers, ‘I’m going upstream to tackle the guy who’s throwing all these kids in the water.’”   

—A public health parable (adapted from the original, which is commonly attributed to Irving Zola), as retold by Dan Heath in his book Upstream.   

Are we solving the wrong problems? Every day we confront a set of problems and issues, but how many of them could have been solved better and easier had we done something about them years earlier? I've been thinking about this lately while musing about the downstream effects of what gets done or doesn't get done.

Last year I got surprising results from my annual blood screening showing that I was prediabetic. I hadn't had to think about blood sugar for my entire life, and now suddenly I did. Prediabetes is a sign that blood sugars are starting to accumulate rather than being converted into energy. It usually presents with no outward symptoms, which is why it's easy to have and not be aware of. But according to Medicare, up to 50% of those 65 and over are prediabetic, many of them undiagnosed. Those who are overweight or obese are especially susceptible.

Without lifestyle changes, prediabetes can often progress to full-blown diabetes. At my current age of 67, I didn't want to face the dangers and expenses of diabetes, including the insulin shots and food restrictions. Diabetes is a disease that causes the body to become insulin resistant, which means that sugars aren't converted to energy, resulting in fatigue plus a multitude of side effects. Increased sugar in the bloodstream can be destructive, especially to the heart, eyesight, hands and feet. Eventually it can kill people, and it is the 7th leading cause of death in the US at nearly 100,000 deaths per year.

Worrying about getting sicker wasn't getting me anywhere; I needed help with a lifestyle change. Lucky for me I found Medicare's Diabetes Prevention Program. (MDPP) This program, I found out, is entirely free for Medicare enrollees and is specifically targeted at those most in danger of developing Type 2 Diabetes, which is the most common form. It involves weekly and then monthly classes with a nutritionist who goes over a curriculum based on current research that will make a real difference.

I started my MDPP class hesitantly, not knowing exactly what would be expected. Our teacher was very nice and knowledgeable, and she went through the prepared material while letting us share our experiences as she provided her expertise. We were expected to weigh in every week and report on how many minutes of activity we engaged in, which kept us all accountable. My class was small- only about six of us- and I learned something new almost every week.

And it worked! My A1C came down a bit and I lost 25 pounds on my own without any pills or shots, keeping most of that off a year later. Many of the things I learned were things that I had already encountered, but hearing from experts in a group setting helped motivate me to make changes. I learned about how to eat better and move more to stave off full diabetes, while confronting many of the things that might be holding me back.

Medicare is expanding this successful program with some powerful new tools. The new Bridge program offers qualified seniors discounted GLP-1 drugs that help them lose weight and improve a large number of conditions. And the new ACCESS program uses Artificial Intelligence to coach those with chronic conditions on how to manage behaviors and improve their health. If utilized, these tools could help countless seniors live longer and better lives affordably.

At my doctor visit, where I was first given the news that I was prediabetic, all he said was to eat less sugar and lose some weight. The whole visit took 5 to10 minutes. He didn't say a thing about programs like this, which is discouraging. If more people in my situation would get the help to prevent terrible diseases like diabetes from ever happening, wouldn't that be a good thing? Our expensive, wasteful medical system is excellent at some things, but for preventative medicine, it fails. Perhaps the new Medicare programs show a sign that is changing.

When you set up a healthcare system that makes money from surgeries, drugs, and tests, what sense does it make to do the work of preventing the very conditions that generate revenue later? Our doctors work hard, but disease prevention is not an emphasis when most of their training is downstream at the critical stages.

The one place where preventive medicine came out of top in the US was vaccines. A simple shot preventing a life-endangering infectious disease? It's preventive healthcare at its best, but even that is under assault now with all of the anti-vax hysteria that has emerged during this decade. People died from Covid-19 because of confusing information and misinformation, and measles may be next.

I recently read the excellent book Upstream by Dan Heath. Heath says that problems aren't handled earlier when they could be solved better because of three reasons:

• Problem Blindness- disasters are natural and unavoidable, so people believe that there's not much that can be done about them.

• Lack of Ownership- It's a problem, but "not my problem".

• Tunnelling- Problems become so big and overwhelming that people give up and look for short-term solutions that only delay the inevitable.

I think instinctually we all know deep down that tackling a problem early and often can overcome these roadblocks. Building up the will and courage is all that's necessary.

That brings me to the ultimate upstream opportunity- childhood. My wife worked for a program called Parents as Teachers, an early childhood initiative through the public school systems that sent parent educators into homes of new parents. The first 3-5 years of child development are critical in shaping many of the characteristics as children grow up, yet for most new parents there is little help during this key period. Parent educators have changed that for good, giving new parents valuable advice while also screening children to detect early developmental problems.

I'm still amazed at how much of a difference this small program has made in so many lives. Founded in Missouri some forty years ago, it has since spread to all 50 states. This program, along with Head Start, universal pre-K programs, and Zero to Three, has changed lives for the better. While some parents don't need much help, many do- and are afraid to ask because it might make them look bad. The results of these programs speak for themselves; graduates do better in school and in life. How much money do we spend on drug treatment and incaarceration for young adults that could have been saved with early childhood intervention and support?

Want to make a real difference in the world? Help a child. Teachers, parents, and counselors are vital to the health of the future, and by the time a person reaches age 21, much of their path is already set. It saddens me beyond words to think of the millions of children who experience hunger, war, physical abuse, and neglect. They could grow up to be our next leaders or terrorists, depending on how things work out.

Prevention is 100 times more powerful than treatment. The butterfly effect states that even small changes today can have large and unpredictable effects later on. Almost every effect in the here and now had some kind of cause in the past. If we could go back in time, we could create a vastly different world by preventing disastrous decisions. By minimizing disease, war, and poverty today, we can make a better future for everyone.

Can you overdo it with prevention? Certainly. While some prepare for things that will never happen, others blithely ignore the signs that danger is imminent. Being overprepared is a waste of time and resources, which is where science and statistics come in. We have enormous amounts of data about things that are and aren't likely to happen, and the most threatening ones are the ones to prioritize preventing. As with everything else, there needs to be a balance between living for today and preparing for tomorrow so that we can enjoy both.

Prevention can be deemed unnecessary and expensive until it becomes obvious that people should have been better prepared. The Y2K bug in 2000 could have caused huge disruptions in the economy, but programmers prepared ahead of time and replaced the old code so dates wouldn't crash computers worldwide when four-digit years became necessary. When no disaster happened, few people noticed or appreciated what had been averted.

The same indifference applies to the Cuban Missile Crisis, the ozone hole, and now even the polio vaccine. We took for granted that those disasters were averted, while the leaders who ignored warnings about real disasters on their watch somehow got a pass. Prevention isn't sexy or exciting, and yes, it can be expensive or uncomfortable. It's still better than the alternative.

Maybe the biggest problem today in the lack of forethought is the rising sense that the future will be dark and grim. According to Pew Research, some 39% of Americans believe that we are now in end times (which kind of makes it pointless to plan for the future). Even worse, the looming crises of the 21st century- AI, climate change, rising inequality, and unsustainable government debt, are causing people, especially young people, to give up hope. Without hope for the future, it feels like our current actions don't really matter.

But we are NOT in end times. Our behaviors DO matter, much more than we realize. By the 22nd century, humans will still be here, trying to live, learn, and grow- and every action that we take now (or fail to take) will affect them and future generations. I stand with Star Trek creator Gene Roddenberry who said:

“I believe in humanity. We are an incredible species. We’re still just a child creature, we’re still being nasty to each other. And all children go through those phases. We’re growing up, we’re moving into adolescence now. When we grow up – man, we’re going to be something!”

My goal for time I have left here on earth is to avoid diabetes and other preventable illnesses while making the most of my remaining years. I hope to plant seeds for the next generation, and the ones after that. My ancestors did the same for me, and it's time to return the favor.

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