PREVENTIVE MEDICINE 1, 15-19 (1972)

Preventive Medicine: The Approximation

of Paradise?

THEODORE COOPER

Director, Nutionul Heart and Lung Institute, Bethesda, Maryland

AND

SHIELA C. MITCHELL

Assistant to the Director, National Heart and Lung Institute, Bethesda Maryland

In the first issue of a new journal devoted both to preventive medicine per se, and to the interface between research and research findings in preventive medicine and the application of those findings to the prevention of disease in the population at large, it is fitting to consider the goals and priorities which underly the need for such communication. This consideration is not prompted by a sense that this new journal needs justification. Indeed, it would be dif- ficult to justify a new journal if its purpose was, in Earl Benditt’s words, “to publish articles replete with detail and barren of concepts”(l). There is a plethora of such already. Rather, these considerations are prompted by the urgent need for presentation, evaluation, and discussion- even if it involves controversy-of this nation’s health goals.

It is usually assumed that these goals are self-evident truths and hence do not require restatement, let alone reevaluation. In fact, this is far from the truth. In the first place, although it is usually couched in other terms, the premise underlying many health plans and research justification seems to be that the basic health goal is the acquisition of immortality. Eradication of a crippling disease, prevention of “premature death,” lengthening of vigorous life, all presuppose for some people, that the name of the game is to live for- ever. Since there seems to be a hesitancy even among scientists to step for- ward and contend that immortality is a feasible and worthy goal in and by it- self, the justification for programs which might lead to this end, is stated in terms of money to be saved. The cost of medical care, the loss of earnings, the depletion of the gross national product, and the diversion of large sums of money from other activities to provide care for the sick, or welfare for the survivors, are the stated reasons why various lines of endeavor should be pursued and funded. In our opinion, these arguments are suspect.

The question of immortality first arose in the Garden of Eden. Although it is generally assumed that man was doomed to die if he ate the fruit of the Tree of Knowledge, a more careful reading of the original text gives no indication that immortality was a necessary attribute of Paradise (2). Indeed, had immortality been part of the original plan it would hardly have been necessary for all the creatures, including man, to be exhorted to be fertile and increase. What hap- pened when man ate of the Tree of Knowledge was that he was then able to

15 0 1972 by Academic Press, Inc.

16 COOPER AND MITCHELL

discern and choose between the good and the bad and hence was at risk of choosing to eat the fruit of the Tree of Life which then would insure that he would live forever. To prevent this contingency, he was expelled from the Garden of Eden. Apparently, immortality per se, was not thought by the peo- ples of Mesopotamia nor the writers of the Book of Genesis as being necessary or necessarily good. Much later Milton was to note that Satan lay van- quished, confounded though immortal. In Paradise Regained, Milton con- tends that the prerequisite to reentry was not to give up the knowledge gained through eating the fruit of the Knowledge Tree hut that being able to discern both good and evil, good was always chosen. Almost as an after&ought, he mentions that fruits from the Tree of Life and drink from the Fount of Life concluded the first banquet in Paradise reentered (3).

This confusion of Paradise with immortality has consequences in social ac- tion which are far from trivial. Were the goal to live forever, any alteration of the general, external environment, of the individual specific interior environ- ment; any change in life style, any alteration of the economic structure of our society would be justifiable. If, however, our ultimate goal is not immortality, then such changes where they involve large segments or indeed the entire pop- ulation require very careful scrutiny.

In a like manner, the claim that prevention of disease and postponement of mortality will pour money back into the National Treasury requires some scrutiny for, at the very least, it makes some assumptions all of which may not be valid. It has been stated, and by those who are either themselves econo- mists of note or who have had access to such people, that arteriosclerosis, for example, costs the country $23.6 billion each year. Approximately $20 billion of this is said to be due to lost wages from morbidity or lost earning power from premature death with $4 billion ascribed to the medical care which these I,850,000 people require (4). But this figure is for patients of all ages and not all of these, by any means, were contributing actively to the gross national product at the time of their illness. Some were retired, some were not and had never been wage earners, and a few, but very few, were too young to have en- tered the market place. Thus, restoring some of these people to health or preventing their disease does not necessarily mean that they would become active contributors to the economy. To be sure, they would be consumers and as such may be more necessary than producers, but this aspect is not encom- passed in the $24 billion figure. Then too, if premature death and disability were prevented among those people who are now active wage earners, thus permitting them to remain or return to their gainful employment, it does not automatically follow that there would be a job available for them or that they would not displace someone else, a healthy, currently available worker, from his or her job putting him in the ranks of the unemployed.

These distinctions are quite apart from the considerations of unduly increasing the number of senior citizens in the country by virtue of preventing premature death. Certainly, if immortality were to actually befall mankind, the number of aged would rapidly rise but the usual calculations are that prevention of premature death, from coronary artery disease at any rate, will

EDITORIALS 17

increase the number of persons who might be considered as middle aged, i.e., under 65 years of age but that these people would be expected to die at or shortly after their 75th birthday. This assumption is based upon a comparison of death rates in the United States and in other Western counties, notably Sweden, which has a death rate from cardiovascular disease for men between ages 35 and 64 of 270 per 100,000 while that of the United States is 554 per 100,000. Yet after age 75 this difference in the death rates between the two countries virtually disappears. Assuming 100% success in preventing prema- ture death from coronary heart disease in men beginning in 1965 and con- tinuing for the next 20 years, with current trends continuing in other disease mortalities, by 1985, 9.5% of the males in the population would be men 65 years of age or older in contrast to the present 8.3% while 12.4% of all females in the population would be women over 65 in contrast to the present 10.4%. Concommitantly, there would be an additional one million Americans, both men and women, between the ages of 40 and 65 if this miracle were to come to pass, and two-thirds of the population would still be under 40 years of age (5). Even these social consequences should have social discussion which they have not had to date, but they pale in comparison to the social problems if absolute prolongation of life is our goal, and we are successful in achieving it.

For reasons which are far from clear, there seems to have been a reluctance to present, consider, and discuss what should actually be the goals of modern medicine. And yet one goal is entirely worthy and clearly becoming increas- ingly acceptable in spheres which relate only tangentially to medicine. And that is the goal of improving the quality of life.

The ecologists, environmentalists, nature groups and consumer advocates do not feel any need to apologize for attempting to improve the quality of our common external environment. As used to be true of motherhood and the flag, improving the macroenvironment is presently considered to be a “good thing.”

Moreover, cleaning up the environment will require a good deal of money and effort, cost and exertion which directly or indirectly will be passed on to be paid by all the citizens. It is hoped that this will improve the health of many; although no one has yet suggested that clean air will give life everlast- ing. But there is no reason to hope, nor has it been suggested, that these changes will increase the gross national product nor improve the economic health of the country. Yet no one disparages the present, and presently planned, efforts on this basis. Perhaps they are afraid to do so feeling that it would be an unpopular idea. But if this is the case, then the point is made that the people are willing to pay for improving the quality of the environment, even though it is expensive and will do nothing except make living “nicer.”

Since this somewhat Hedonistic philosophy is acceptable for the external environment, perhaps it would not be too out of place to at least suggest an Epicurean approach to our internal environment, which is to say, our state of health. The philosophy of pleasure has received short shrift in the United States, possibly because of our Puritan background and possibly because our native philosophers have been largely of the pragmatic schools (6). Nudged

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by the problems of excessive numbers in the area of population increase, the time may now have come to move from equating success with large numbers, whether these be dollars accumulated or days of life, to a qualitative society where success is measured in terms of the opportunities for happiness which it provides. Happiness has been defined in almost every conceivable way, but that which permits the exercise of all one’s talents along lines of ex- cellence, -or- the most efficient functioning of man, being restoration of Par- adise where, knowing good from bad, and good is chosen-would seem to be reasonable definitions. This implies, of course, that each person is free to choose and this presupposes not only a healthy macro- and microenvironment but also an absence of coercion whether this be economic, social, or philo- sophical.

Clearly, this requires that all people in our society be able to determine and to choose what is good or bad for themselves. In the context of preventive medicine this is usually referred to as the identification of risk factors. But it means as well that the people must have ready access, which usually requires that the information be brought to them, as to what these risk factors are, how they can be ascertained and whether or not a given individual is susceptible. It means that there should be not only ready, but equal, access for all who are at risk to minimize this risk whether this be the choice of food, the habit of ex- ercise, the smoking of a safer cigarette, or the judicious use of appropriate medication. In essence, this means that preventive medicine would begin with denotation-that is the identification of the particular person at specific risk and then move to connotation (7) whereby an entire class or genera is in- volved, rather than moving as it has tended to do in recent years, in the reverse direction. All of these roles, this Journal can and should play-since there is a critical need to make the choices known both to physicians and to the lay public.

But a serious mistake would be made if prevention was considered only in its primary sense which is the prevention of disease processes. Nor would this mistake be corrected if the search for measures of health as opposed to the search for measures of disease were successful.

To be sure, medicine’s long preoccupation has been with the retrieval of individuals from catastrophic disease. However, a swing towards the preven- tion of the onset of disease, like all good customs can also be corrupted, both by being overdone itself and by displacing other concerns. The prevention of morbidity, of pain and distress due to disease must not be ignored if the qual- ity of life is indeed to be improved. Understandably, no one Journal can take on the task of explaining all the therapeutic modalities that are, and will be, available for all diseases to all readers. But a journal, Preventive Medicine, has a responsibility to at least acknowledge, if not encompass, the prevention of these manifestations as well as the prevention of disease processes. The joy is just as great if one’s capacity for physical and aesthetic pleasures is restored as it is if this capacity has never been lost. So there must be room in our society, and a welcome place among those who practice public health or preventive medicine, for those who treat, as well for those who prevent, disease. This

EDITORIALS 19

welcome should extend to those engaged in rehabilitation for they too are necessary if we are to be able to approximate Paradise.

And we think that Paradise can be approximated if we understand and mutually agree that the goal is to improve the quality of life, to prevent disease and certainly to prevent premature death wherever and whenever we can, but not to imply, nor to attempt to obtain, extension of life to, or toward, infinity if this necessitates a reduction in the quality of life. Given the present problems and the current state of the art there will be more than enough for everyone to do in reconstructing Paradise. But it can be done and this Journal should become an effective instrument in this reconstruction process. Nor is any apology necessary for suggesting that philosophy and even semantics are a proper concern of both the medical and lay public. One of the best known, most profound and original of our American philosophers, C. S. Pierce has said, “It is terrible to see how a single unclear idea, a single formula without meaning, lurking in a young man’s head, will sometimes act like an obstruc- tion of inert matter in an artery, hindering the nutrition of the brain and con- demning its victim to pine away in the fullness of his intellectual vigor and in the midst of intellectual plenty” (8). If this is true for an individual, it is ter- rifyingly true of a society.

The national health goal cannot be assumed; it must be carefully thought through and conscientiously discussed. Such thought and such discussion require leadership, both in the initiation and in the conduct. Much consider- ation will be needed and all points of view should be aired, so that all may know what the primary goal in medicine is. Knowing what is hoped for will make it much easier to appreciate when it has been achieved. But to achieve better quality of life for all, means that the options must be clearly stated. In- formed consent is only a way station to informed choice. Informed choice requires not only more knowledge, new knowledge, but it also requires much more dissemination of our presently available information to many more peo- ple. But then little that is worth having is easy come by and happiness is well worth having.

Paradise can, if we choose, be approximated.

REFERENCES

1. BENDITT, E. Pathology and the future. Hum. Pathol. 2,337-339 (1971). 2. SPEISER, E. A. “Genesis Translation and Annotation,” Chaps. 2 and 3. Anchor Bible Series,

Doubleday & Co., 1964. 3. MILTON, J. “Complete Poetry and Selected Prose of John Milton,” pp. 93, 451. Modem

Library, Random House, New York, 1950. 4. National Heart and Lung Institute Task Force Preliminary Report on Arteriosclerosis, June 30,

1971. 5. FREDRICKSON, D. S. Convocation lecture: Cultivating prognosis in cardiovascular research.

Amer. J. Cardiol. 21, 753-758 (1968). 6. TRUEBLOOD, D. E. “General Philosophy,” p. 339. Harper and Row, New York, 1963. 7. MILL, J. S. “System of Logic,” pp. 20. Longmans, Green, New York, 1906. 8. PIERCE, C. S. “The Use and Misuse of Language” (S. I. Hayakawa, ed.), p. VIII, Fawcett,

Greenwich, CT., 1970.