Almost 300 years ago Benjamin Franklin, one of the founders of the United States, stated “An ounce of prevention is worth more than a pound of cure”. In healthcare today, this could never be more true. Not only can prevention decrease suffering and the likelihood of death, it is typically cost effective. Knowing a stay in an intensive care unit (ICU) can cost up to $10,000 per day, and that an ICU stay can last weeks, it is not surprising that a good prevention strategy often saves health systems money.
There is an entire field of study behind this called cost effectiveness analysis (CEA), well known to those who have trained in public health and health economics. The basic concept is that for each intervention, measures such as the number of years of life saved or amount of money saved are calculated. Many vaccination programs are among the most cost-effective interventions, while some prevention programs may not be cost effective at all. The CDC discusses the cost effectiveness of various interventions for several chronic disease here.
Some prevention interventions are expensive and may cost more than $100,000 to save one year of life. Some can be inexpensive though, for example, my friend and colleague Sam from Haiti was treating patients during a Cholera outbreak many years ago, and one day took a megaphone to the Haitian community to spread prevention strategies. In days the outbreak in the community was controlled, and it just cost a megaphone and shifting of his time.
Two of the most cost effective yet overlooked ways to prevent disease involve both patients themselves and influential leaders.
Patients who have overcome a disease can be powerful advocates to prevent a disease. I have seen many patients instantly stop smoking, begin exercising, and change their diet after experiencing a sudden heart attack. The patient’s voice becomes a powerful prevention tool by promoting a lifestyle change to others they know such as their friends and family. An organically turned patient advocate carries minimal cost.
Influential figures such as athletes, actors, and government leaders can play a key role in prevention at low cost. Through their ability to mass influence, public health messages can pulse through a population simply through their influential voice. For government leaders, their influence as a both a policy maker and a public health advocate increases their ability to drive prevention efforts, and ultimately save lives and decrease costs.
During this COVID-19 pandemic, we have seen multiple governmental leaders contract the SARS-CoV-2 virus leading to a diagnosis of COVID-19. These leaders that recovered had an opportunity to encourage prevention and create powerful public health messages across their nations as they instantly carried the dual role of both patient and government leader. Unfortunately, many of these leaders missed this opportunity, and some even worsened the situation by detracting from factual, proven, science based, cost effective public health interventions. Leaders who minimize the impact of and tell others to not worry about COVID-19 after contracting the virus negatively affects our public health efforts. It is analogous to a patient who is a smoker and unhealthy eater (both high risk factors for cardiac disease) who suffers a heart attack and then undergoes the placement of a cardiac stent, but then after recovery promotes the continuing of an unhealthy diet because they conquered their heart disease despite eating unhealthy and smoking. It sounds non-sensical, because it is, yet it has occurred far too often with COVID-19.
There is much we have to learn about this virus. In less than one year, however, we have learned a tremendous amount - perhaps more than any other disease in history over a short period of time. We know some public health practices that work - physical distancing, wearing masks, remaining home with even the mildest symptoms, washing your hands, limiting your contacts, avoiding both large gatherings as well as poorly ventilated indoor areas, and robust contact tracing and testing. If people and systems follow these public health guidelines, we can at least control the virus, thereby quieting the disease down and ultimately allowing us to open the economy more. We have seen this done well in many countries such as Taiwan, Hong Kong, and others. Even within the United States we have seen significant differences in regions that follow guidance and those that don’t. Compare the city of San Francisco to the state of South Dakota, both with approximately 890,000 people. One would expect the dense city of SF to have a higher number of cases than an sparsely populated state, but through sound following of mask wearing and other public health interventions, they are averaging just 50 cases per day compared to South Dakota’s 1,121 cases per day. In South Dakota 3x as many people who have died from the virus, and the gap is widening. These are sadly preventable deaths.
We know that to ultimately beat this virus we require advances in diagnostics, treatment, and a vaccine. Significant funding should be allocated to these areas. However, too often we overlook behavior, education, policy, and leadership and not only should funding be allocated to these areas, but we must capitalize on the free, low cost interventions available to us. With great power comes great responsibility, and those governmental leaders have a responsibility to not only develop sound COVID-19 policy by selecting the right public health intervention at the right time, but also serve as public health advocates if they contract COVID-19. Having said all this, there is a tremendous amount of fear and anxiety in the population, and the leader at the same time must convey the importance for people to not live in fear. I spend a large portion of my time strongly advocating for evidence based public health interventions, while at the same time attempting to keep people positive and calm. This is not an easy task, but the ability to articulate and communicate such a paradox is the art of leadership, and is what is required of leaders in this crisis.
The most important political issue for almost every country right now is their ability to contain COVID-19. A leader's ability to contain the virus will determine the fate of not only their economy over the next few years but will also determine how many more of our fellow neighbors and citizens we will lose in this battle.
Vipan Nikore, MD, MBA is the CEO and Cofounder of Homecare Hub, the Chief Medical Director of TD Bank Group, an internal medicine physician at the Cleveland Clinic and Trillium Health Partners, founder of uFLOW, and an Assistant Professor at the University of Toronto Faculty of Medicine. He has been teaching healthcare leadership for over a decade. His posts are personal views and do not necessarily reflect the opinions or positions of any organization he is affiliated with.