Editor's Pick

Prevention Is Better Than Cure

Modern medicine is overwhelmingly reactive rather than proactive. Get sick, seek medical help. How expensive that model is! If everyone only got sick and then sought medical assistance, we could not afford the bill. It is much better that most people are healthy enough at any one time that they do not need medical care—for the people themselves, for the economy, and for the whole medical profession.

It is better to prevent disease rather than to try to find cures for diseases after they occur. The reasoning here is similar to why you change the oil in your car rather than wait to fix a blown engine. This is also why we try to vaccinate or inoculate against as many diseases as possible. It is at the level of prevention that most bioengineering efforts ought to be directed, because prevention is better than cure.

The Past as Path to the Future

The path to a cure is usually an arduous one. At one time, leeches, blood-letting, and plying with mercury were the cures of choice. Cholera was thought to be caused by breathing “miasmas,” and treatment was given to dilute the odors associated with the disease. Once it was found that microscopic creatures were what caused this and other diseases, treatments changed, and sanitation became the chief means of disease prevention. Human population health owes more to sanitation than to all the cures developed before or since.

The discovery of antibiotics further changed this prevention mentality. Once again, diseases could be cured with medical treatment: in this case, by swallowing a pill. But living microbes are flexible creatures, and they began to develop a resistance to one antibiotic after another. The appearance of methicillin-resistant Staphylococcus aureous (MRSA), an infection resistant to one of the most potent of the panoply of available antibiotics, caused grave concern bordering on panic in many hospitals.

It is interesting that a remedy described in a 1,000-year-old English document has been discovered to be effective against stubborn microbial infections [5] and shown likely to be more effective than modern antibiotics for treating the very difficult to control MRSA infection. The remedy consists of a mixture made from wine, garlic, cow bile, and copper. When tested against microbes in the lab, this concoction killed up to 99.9% of the bacteria it was tested against.

Preventing Medical Mistakes

Cures often involve medicines, but there are pitfalls associated with these. For example, a reader wrote to People’s Pharmacy [4] about noticing a prescription filled by a pharmacy on one occasion that contained pills looking different from those received on previous visits. Upon careful examination, this person found that the medication in the bottle was meant for someone else—even though the paperwork attached to the bag matched the person’s name. The reader returned immediately to the pharmacy and explained the error. The people at the counter didn’t believe an error could have been made, but the reader was persistent. When the pharmacist looked at the bag and then the bottle of medicine inside it, she recognized that the bag and medicine bottle were designated for two different recipients and reacted in horror that such a mistake could have been made, let alone by someone in her department. Since then, the reader always assiduously checks the prescription to see that it is correct.

This reader’s experience was apparently not unique. A study of 100 randomly selected pharmacies given prescriptions to fill found that 22 of these involved execution errors, and, of these, three could have been harmful for the prospective recipient. There were instances of wrong or no information given about the purchased medicines and interactions with other purchased drugs [3].

And modern medicine, as amazing and sophisticated as it is, has not always been good for patients. A study of five doctors’ strikes between the years 1976 and 2003, each lasting between nine days and 17 weeks, showed that population mortality either stayed the same or actually decreased over the duration of the strike [2], [16]. A recent study by Makary and Daniel [12] analyzed information from a number of sources and concluded that medical errors are the third leading cause of death in the United States, after heart disease and cancer and ahead of respiratory pathologies. Medical errors, ranging from incompetent diagnoses to simple miscommunications, result in an estimated 250,000 or more deaths per year, or 9.5% of all deaths annually in the United States. Modern medicines, as well, can contribute to poor health and addiction in some cases; heroine addiction and fatal overdoses have been blamed, in part, on the overprescription of opioid painkillers [1].

The state of Maryland is experimenting with a new Medicare insurance payment program that pays hospitals a fixed amount for each patient rather than the standard fee-for-service payments for each test or doctor’s visit [14]. As a result, fewer medical procedures have been performed on patients, and that has resulted in a 26% drop in infections, surgical errors, and other unfavorable conditions [15].

Preventing Disease Before It Begins or Spreads

As Sonia Shah notes in a recent survey of pandemics [17],

Over the past fifty years, more than three hundred infectious diseases have either newly emerged or reemerged, appearing in territories where they’ve never been seen before. Ninety percent of epidemiologists expect that one of them will cause a deadly pandemic sometime in the next two generations. It could be Ebola, avian flu, a drug-resistant superbug, or something completely new.

Here is an opportunity for biomedical modeling to predict when and where these possible pandemics are most likely to occur and, following on that, to devise methods to prevent these emergent diseases from appearing and needing cures. Or, perhaps, target diseases could be identified for vaccine development proactively rather than retroactively.

Wearable sensors developed by bioengineers are causing a revolution in medical monitoring, and they will prove to be a real help in the diagnosis of disease precursors, leading to prevention of disease conditions before they become debilitating [9], [10]. That is prevention before the need for cure. There is even a promise that wearable sensors can be used to prevent the development of mental illness. Dr. Rosalind Picard has said [13],

We want to be able to understand what these signals look like as the patient is transitioning to disease, develop algorithms that can pickup the warning signs, and provide enjoyable ways to engage patients in prevention. This would be much better than waiting until they’re in trouble and have to go to the doctor because it has progressed to a serious medical condition…. [It] is time to do this to identify behaviors for reducing the risk of mental health disorders.

The United States does not have the best record of caring for the needs of its military veterans long after they have served in hostile engagements. Imagine if the onset of posttraumatic stress disorders could be detected by wearable sensors worn on the skins of soldiers before the conditions develop fully. How much pain and suffering by the veterans, their families, friends, and acquaintances could be prevented, and vast amounts of money saved, if that goal were to eventually come true?

Prevention Takes Many Forms

I have written before about the excesses of medicine in our litigious society and how preventive measures trump the need to develop cures [7], [8]. My own research has for years been concerned with the use of respiratory protective masks and the means to make them more wearable by quantifying psychophysiological factors impacting the functioning of respirator wearers [11]. Respirator masks can protect workers against inhalation of airborne contaminants, but only if the masks are worn or worn correctly. Understanding performance decrements that may result while wearing masks can assist designers in improving these masks and can direct managers to assign additional help if task performance by wearers is degraded too severely.

Prevention is better than cure. Perhaps someday this rationale may also be used as the justification to edit the genes of human germ cells, although that is a huge step that will require much deliberation before it becomes reality. Once that step is taken, there will be no going back. Nevertheless, human-induced pluripotent stem cells are already being modified to satisfy the somatic cell replacement needs of advanced-stage neurodegenerative disease patients [18]. Many of these diseases present no symptoms until long after large numbers of cells have been lost. Huntington’s disease is typical, only showing symptoms later in a person’s life. There is no satisfactory cure for Huntington’s (although see [6]). In vivo gene editing can be used during the preclinical stages of Huntington’s to cure the disease before it debilitates those who inevitably would suffer its symptoms. This, in effect, is prevention before cure.

Bioengineers and biological engineers have an important role to play in human health maintenance. Their work directed to preventing disease can be very important for avoiding the downsides of medical care given in reaction to the contraction of maladies that are avoidable. It is here that they can make the most important contributions to human health and well-being.

References

  1. American Industrial Hygiene Association, “Opioid abuse and workers’ compensation,” The Synergist, vol. 27, no. 2, p. 38, Feb. 2016.
  2. S. A. Cunningham, K. Mitchell, K. M. V. Narayan, and S. Yusuf, “Doctors’ strikes and mortality,” Social Sci. Med., vol. 67, no. 11, pp. 1784–1788, Dec. 2008.
  3. E. A. Flynn, N. B. Kenneth, B. A. Berger, K. B. Lloyd, and P. D. Brackett, “Dispensing errors and counseling quality in 100 pharmacies,” J. Amer. Pharm. Assoc., vol. 49, no. 2, pp. 171–182, Mar.– Apr. 2009.
  4. J. Graedon and T. Graedon, “Don’t count on pharmacy to be above making errors, reader letter to people’s pharmacy,” Baltimore Sun, p. C4, 18 Feb. 2016.
  5. F. Harrison, A. E. Roberts, R. Gabrilska, K. P. Rumbaugh, C. Lee, and S. P. Diggle, “A 1000-year-old antimicrobial remedy with antisthaphylococcal activity,” MBio, vol. 6, no. 4, p. e01129, Aug. 2015.
  6. E. Hopkins, “Fighting Huntington’s Disease,” The Shepherd, vol. 61, no. 2, pp. 14–15, Feb. 2016.