According to the Internet, Benjamin Franklin said “an ounce of prevention is worth a pound of cure” sometime towards the end of 1736. He was making reference to fire safety and not to public health; germ theory was over 100 years away and while diseases that were preventable simply by employing good hygiene were killing thousands of people, these deaths were mysterious and void of the spectacle associated with fires. Today, in most western countries, fire prevention technologies are so effective and ubiquitous that most fire fighters spend the majority of their time attending MVA and medical calls. This is fantastic, but it only happened because most fire departments are run by the local government as not-for-profit essential services.
Compare this to what most people assume the quote is making reference to, health. The statement remains true in this realm, but the nature of the health industry is very different from that of the fire fighting industry. For one thing, it is much larger in scale because life is very complicated and maintaining optimal health can be achieved in a number of seemingly very different ways. The causes of sickness and disease are numerous and there is a very large life style component to it. Cancer, for example, can be caused by exposure to chemicals and different wave lengths of electromagnetic energy that are naturally occurring, but these carcinogens can also be consumed in quantities that are much greater than what occurs naturally in the environment. This allows for people to twist the narrative in such a way as to blame the person with lung or skin cancer for the emergence of the disease. It may not be demonstrably true, but human beings who have a vested interest in convincing people to believe a particular thing tend not to realize the role this conflict of interest plays in their efforts to propagate a story of Randian personal responsibility.
This, when coupled with the length of time it can take for a disease to run its course, makes possible something that fires do not, the creation of a number of profit centers that have the illusion of being concerned with addressing the illness. With fires, you have two unique inflection points, before the fire and during the fire. Before the fire we have prevention. During the fire we have suppression and elimination. Generally speaking, government regulations are the realm of prevention and suppression while municipal fire departments are concerned with verifying the completion of the prevention activities and performing the elimination activities (the actual hands on efforts to put fires out once they begin). The private sector is involved in all areas, but primarily in the manufacturing of fire prevention, suppression, and elimination of equipment used in these tasks. General motors manufactures fire trucks, various machine companies make water pumps, hoses, and water proof gear, GE makes smoke detectors, other companies make metal pipes and sprinkler heads for fire suppression systems, and various manufacturing companies make the electronic components and devices that are used for monitoring heat and smoke. Other companies will sell services that support and ensure that the government regulations are followed and that buildings are up to code.
From a capitalistic point of view, there is some money and many civil servant jobs in fire elimination, but the bulk of the profit is generated in the manufacturing and sale of the equipment that addresses the prevention and suppression aspects of fire. This is actually how it should be and it is not a random outcome. There were times when fire departments were privately owned for-profit ventures and this lead to the very predictable outcome of services being denied to people / companies that could not afford to pay the price being demanded to put their fires out. Fires spread however, so this arrangement became unworkable very quickly as a fire that burned in the house or business of a person who could not afford to pay the private company to put it out would quickly become a fire that was burning in the neighbouring houses. City blocks would be destroyed unnecessarily simply because the fire department was a private venture that decide on the cost and withheld the service from those unwilling or unable to pay for it.
This needs to be compared to the health industry, which is profit driven at nearly every step. The only piece that is not completely infected by capitalism is that of single payer or socialized health care which is only just mostly infected by it. Canada is a good example of a single payer system that serves to line the pockets of nearly everyone involved. While the citizens and permanent residents of the country will get treatment if they go to hospital or a health care provider, not everything is covered and there is an incentive for the providers to adopt a mostly transactional methodology when administering services. The users need to pay out of pocket for many things and while the government has attempted to eliminate the possibility of a two tiered system, it is not entirely illegal for a doctor to charge their patients for certain services, particularly unproven treatments that may or may not do anything.
As is the way with people when incentives are involved, some number of the providers WILL act in the ways that ensure that they maximize the amount of money they make. This can be an ugly mark on the illusion of socialized medicine, but it tends to manifest itself in all of the areas other than treatment of acute illness and life threatening disease. For example, if you break your leg, the hospital will diagnose and treat you, if you get cancer, you will get access to the specialists who are trained to treat it and to the medications that have been scientifically proven to destroy the cancer cells. You will not, however, be given free access to emerging treatments that have not yet been proven effective or deemed to be effective treatments by the provinces health ministry. Some medicines that are free to patients in British Colombia are either not available to people in Ontario or are available only to those who are willing to pay the drug company directly for them.
The situation is worse for non-fatal or terminal illness, diseases, or pathologies . Connective tissue injuries like ligament tears or cartilage damage are treated using an opportunity cost model more than the triage model. Someone who is younger, an athlete, or who has a very high earning potential, will get access to treatment much faster than someone who is older or is retired. Statistically this is a good approach given that the government stands to collect more tax revenue for a person who is highly skilled and closer to the beginning of their career than someone who is retired and living off of their savings or social welfare programs. The opportunity cost of delaying treatment for the currently employed is much higher than it is for the person who is in the twilight of their life. Even if we were to factor money out of it, which is impossible, fixing an ACL tear for a younger persons will statistically lead to a greater increase in the time of restored mobility than fixing it for an older person – a 25 year old person may get 55 years while an older person might get 3. Statistics do not deal with the individual cases, so the sound logic of treating the younger contributors before the older no-longer contributing will not have an impact on the older person who is delayed treatment, but the approach the government is taking is at least defensible from this perspective.
Another characteristic that makes things foggy is the role that soonness and salience play in evaluating and ranking risk. Human beings are almost powerless to do anything other than believe that negative outcomes that are going to occur soon and that are very easy to imagine are worse than the ones that will arrive later or that are tough to get a handle on. A fire that is burning right now is much more dangerous than the 4 instances of skin cancer that are on someones back. Fire triggers a visceral feeling while early and mid stage cancer remain primarily abstract. Everyone can see the value of preventing and putting out fires quickly, it is much harder to see the problem that cancer is causing within a person until it crosses into the realm of a health crisis; at which point it is probably too late to actually cure the person.
This creates a problem for people in assessing risk and determining value of prevention. While a fire may destroy a row of houses, as long as the people and pets get out, most things can be restored within a few months. It is more than a simple inconvenience, having your home burn down can be life altering, but if the living beings get out of the house, it is going to be life threatening only to the fire fighters. And yet when we happen across a fire in progress, it is a compelling sight, one that seem to mandate attention and action.
Cancer, obesity, chronic stress, mental illness, etc… do not have this salience. We likely see people who have cancer everyday and go about our business as though they are not on fire from the inside. We when encounter an obese person, any negative reaction we have has nothing to do with their increased all cause mortality risk and is more likely to come from a value judgment about what we perceive are their life style choices. Those we encourage who are suffering from mental illness or chronic stress tend to be categorically dismissed as being weak in the head or in need of some relaxation. The physical nature of these diseases is invisible and we cannot see that their bodies are actually running so quickly as to be physically burning out.
I have no doubt that if Benjamin Franklin was alive today that he would make the same statement, this time about health. But with more authority and urgency, because the cost of prevention is so much lower than the cost of these diseases running their course. And I have no doubt that people would agree with him and “like” his post before returning to worry about things that are bright and shiny, and much less of a problem than cancer. Each year in the US just under 3 million people die; of which about 3500 deaths are attributed to fire and 609640 are attributed to cancer. This means 0.124% of the total number of deaths are due to fire while 21.67% are the result of cancer.
This begs the question, why are we all so misguidedly idealistic? Or why is there a pragmatic void when it comes to risk assessment?
Well, there are two reasons, the first is that our statistical intuition is dreadful and the second reason is money.
Regarding the first, there is a cognitive bias labelled “the law of small numbers” that captures the human tendency to overweight the importance of a very small number of occurrences and to then generalize or apply this exaggerated significance to the general population.
However, and I believe that this is the most important part of it, people can learn the facts and then apply them to life EVEN if they never actually gain the ability to do it intuitively. They just need to learn the information, create a rule to guide their thinking, and then put in the effort to use the rule by consciously thinking about the relevant subject. KNOWING that they cannot trust their innate thinking about the topic and having the willingness to put in the mental effort are the only things that are required to get it right. But this is neither natural nor is it cost free.
The Monty Hall problem, for example, is something that I now understand but still don’t feel completely comfortable with. My guess was that the odds did not change once one of the possible choices was eliminated. But, having looked at the math, it clearly makes statistical sense to switch your choice. Even still, it doesn’t feel that way. The odds seem to have gone from 1 in 3 to 1 in 2; this is only the case when you switch choices – and even then, a mathematical case can be made for an improvement in the odds from 1 in 3 to 2 in 3 but only if you switch. I do however get the question right now because I learned the correct answer, studied the relevant math and committed to memory the fact that my brain makes this error.
My incentive for putting in the work to learn how to avoid these types of mistakes is a desire to avoid being wrong or the desire to be right in the future. For whatever reason I am motivated to operate this way – likely because my brain responds very well to thinking and releases a big reward when it figures things out.
In this case, no one has a vested interest in withholding the information that is needed to inform my understanding and to illustrate how I can avoid making statistical errors. Monty Hall himself became aware that there was a benefit to switching after one of the three options was revealed not to be the big prize, so his suggestions to switch were likely an earnest attempt to actually help the contestants out. So even though the information was available, very few people knew it, and fewer still went onto the show Let’s Make A Deal to put it to work for themselves.
The key consideration with cognitive biases and the errors they contribute to are that they are well documented, proven, and discussed. It is not a lack of wisdom that is preventing people from educating themselves and taking the necessary steps to avoid making the mistakes that they cause. This is not done by most people for one of three reasons: a lack of an incentive to learn and take steps to avoid them, the existence of a disincentive to learn about them, or an external variable. In the case of the law of small numbers, as it applies to health, it is primarily the third reason.
Money, and specifically other people making as much money as they can, is the external reason why most human beings favour salience over statistics when it comes to managing health risk. All of the companies that stand to make a profit from treatment have a number of people on staff who are very aware that preventing an illness or disease will lead to a much better outcome than relying on their company’s treatment. But the majority of the marketing budget is directed towards proving the need for and advertising the availability of their products. They have a vested interest in selling the problem and solution (treatment), and this conflict of interest stops the entire company from doing anything to educate their potential customers about the law of small numbers, the value of prevention, and the quality of life benefit to anyone who puts in the work to avoid the need to ever become one of their customers.
This is a slight head scratcher to me. Not the actions of the corporations that sell health treatments, but the lack of action by their potential customers. On one hand, I understand and accept that putting effort into doing anything that is different from our automatic behaviour feels like and IS work. It has the very real sensation of “paying now” for something that is so far in the future that it doesn’t exist. The effort spent today cannot easily be viewed as the cost of a long healthful life and is instead experienced as a loss of something scarce and very valuable. But on the other hand, there is no denying the existence of disease and illness. Cancer, for example, is something that is very real and which society no longer has any difficulty talking about. Most people who reach adulthood know at least one person who has died from cancer and a few people who have gotten it. Practically everyone knows that food choices and ones level of activity are correlated with disease and illness risk and yet obesity and inactivity are now major contributers to decreased life and health span. The belief that technology and science will offer up a suitable treatment when sickness punches our ticket is an understandable, while overly optimistic, rationalization for not doing enough to prevent illness.
During all of my time working at gyms and in the fitness industry, it was painfully obvious that less than 10% of the population who were not athletes or fitness enthusiasts would ever make the move into one of these groups. I am biased here, but all evidence points to moderate amounts of intense physical exercise and the mindful eating of appropriate amounts of food, mostly plants, as being preventative measures in terms of disease and illness. The cognitive enhancement benefits of improvement in circulations, along with the increase in energy / vitality are massive bonuses. However, there seems to be a prevailing belief that there are chemicals we can take that will mitigate all of the negative effects of not taking the actions that have been proven to help us delay and avoid disease.
This is where I begin to blame the corporations and other companies. While they are not responsible for the things that people hold as truths, they are responsible for selling them the promise and the chemicals that will treat whatever comes along. Their efforts and motivation to sell more of their products get them to play their role, which is at best misleading / incomplete and at worst a blatant lie, in the cooperative act that results in us buying their treatments.
There is a saying that is credited to Henry Oberlander that captures the fact that everyone is willing to give something in trade for whatever it is that they want. On our side of the table is the desire (want) to change nothing about how we live our life and on their side of the table is the promise of a treatment for the negative outcomes of a life not lived with an eye on the needle of preventative actions. It’s a win win insofar as we get to feel safe and secure that we can change nothing and our future will be fine and they get to feel rich. Except ours is just a feeling while theirs is a fact.
To their credit, most of the treatment sellers are NOT engaging in a campaign of outright disinformation and many of them are selling goods and services that are an effective treatment. You can take the pills every day for the rest of your life and die from something other than the disease you didn’t prevent. In this regard, the treatment is kind of like a cure, except for the fact that the company gains a life long customer and the customer gains a life long dependence on an exogenous chemical or external service to make-up for what their body cannot do, but must have done, because of the illness.
So what?
Prevention is effectively the front loading of effort and it is a gamble. We work today in the hopes that we are able to shape the future and cause a very specific outcome. Life does not last forever and over its course the body begins to breakdown and lose its ability to fix itself. Prevention can be viewed as the taking of specific actions that have been demonstrated to extend these self-repair mechanisms OR avoid those actions that have been shown to destroy this innate ability.
Human beings have a preference to avoid spending energy, mental or physical, and will only spend it when they have an incentive to do so. The consequences of not taking preventive action are so far in the future that they do not register as a disincentive for NOT taking known harmful actions. The same temporal distance also serves to negate the incentive someone has for taking preventative actions.
Our brains are not very good at dealing with statistic so we have a tendency to make gross generalizations or to create ALL or NOTHING rules to increase cognitive ease when thinking about things. When we are given a solution to a problem that we do not have, we will update our understanding of the world and the implicated subject to include the fact that the problem has a known solution. The operational impact of doing this is the perception that the risk associated with the problem has been eliminated. This grants us an unjustified freedom of action because our brain holds the belief that there are no consequences to any action that might lead to the problem.
We WANT to believe that the future will be safe and the same as or better than the present. Anyone who wants to sell you something can leverage this desire by presenting their product or service as a solution to a future problem. While there is a philosophical difference between a treatment, a cure, and never needing either, there is no actual distinction between the three when exist only as future possibilities.
Living a good life, one full of the actions that promote long term health and void of the actions that harm it requires effort and sacrifice, and the outcome is never a sure thing. While we may one day become old, we are alive right now and open to the pleasure and joys of a diverse range of activities and actions. Saying “no” to immediate reward in favour of a future possible reward just doesn’t have the same kick as saying “yes” to what we can have right now.
The important thing to keep in mind is that your actions now will have an impact on the person you live to become. While the treatment for the consequence of your poor actions, or lack of action, may seem like something future you will be fine with, present you has a conflict of interest and therefore cannot be trusted. They want to experience the pleasure of doing what they want all while NOT having the disease or illness at preventative actions might eliminate.
You need to take sometime to have a good think about your future and really get a handle on what you want it to look like and how you want it to unfold. Hypertension, diabetes, obesity, and impaired mobility, while not necessarily real to you today, are very real for a lot of people who didn’t look after themselves as well as they should have. Their present experience is that of someone who is relying on treatment to combat things that were mostly avoidable. Some of their money is going to people and companies who have a vested interest in a growing population of sick people.