Ethics and Prevention of Chronic Disease

Short Communication

We hear much discussion about healthcare coverage and costs associated with insurance, pharmaceuticals, surgical interventions, and related issues. All of these are important but leave out perhaps the most important strategy prevention.

Facts We Must Acknowledge

The urgency of addressing chronic disease can’t be stressed enough these conditions account for over 86% of our healthcare costs, and much of this is preventable [1, 2]. This literally means that if invested in properly, we could spend $240 now on prevention instead of $1000 in the future on reactive healthcare costs for chronic disease. Healthcare costs are only the tip of the iceberg. Absenteeism (time taken off due to illness or other reasons) and presenteeism (attending despite an illness that prevents full functioning) in school and at work take a significant toll on family life, the ability to plan for their future, and our global economic competitiveness [3].

Almost every American family is adversely affected by chronic diseases in one way or another through the death of a loved one or family members with life-long illness, disability, or compromised quality of life. These burdens affect society on both the personal and community level, not just in the physical disease, but also in the financial burden that comes with the cost of chronic disease [4].

We are beginning to see the impact of the Covid 19 pandemic on the population. This burden isn’t carried equally, black and Hispanic people, seniors, and other groups carry a disproportionate share, very much the same as many chronic conditions. This is further evidence that health risk for these groups including people in poverty outweighs many factors previously credited with differences.

At a time when our investments in housing, education, and medical care have outstripped inflation, our investment in prevention has lagged far behind. Today we fund prevention efforts at approximately the same amount we did in 2001, effectively a funding cut of 22.92% when inflation is considered.

To summarize and focus let’s consider a reality check:

• As of 2014, 60% of American adults had at least one chronic condition, and 42% had more than one chronic condition.
• Chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the United States. 7 in 10 leading causes of death in 2017 were chronic diseases, totaling about 1.75 million American deaths.
• More than 86% of the nation’s healthcare costs relate to chronic diseases, and most of those costs are preventable [5, 6, 7, 8].
• The projected prevalence of any cardiovascular disease in the United States will increase by 3% to over 45% by the year 2035 [9].
• Risk factors such as poor diet, lack of activity, alcohol abuse, and ignoring medical advice all contribute too much to this crisis.
• 27% of young adults are too overweight to serve in the military [10].

Change is Overdue

We have created a culture where the healthy choice is often the hardest choice at every stage of our lives. We know we need to eat better, be more active and avoid tobacco - but we’re cutting back on recess and physical education, cutting back on the ability to be active in our everyday lives and tobacco is still all too available, especially to children [11, 12, 13, 14, 15]. The CDC estimates that modifying three risk factors poor diet, lack of physical activity, and smoking can prevent 80% of heart disease and stroke, 80% of type 2 diabetes, and 40% of cancer. Good, healthy food options are more available today but not everywhere and not for everyone. If we are serious about improving the lives of Americans, having an impact on healthcare costs, reforming our system, and reducing disparities, we need to invest in a meaningful way in prevention [16, 17].

We can Bring Chronic Disease Prevention Up to Scale

Today, only a fraction of 1% of federal healthcare investment goes to prevention this is a breach of an ethical approach to public policy, especially since we know better. Even with this limited funding, states are implementing diverse, cost-effective strategies that work for early detection of cancer, prevention and control of diabetes, reduction of heart disease and stroke, reduction of the disability associated with all these conditions, and beginning key programs targeting arthritis and Alzheimer’s disease using the latest science. To continue this work, there needs to be a substantial investment in CDC’s National Center for Chronic Disease Prevention and Health Promotion to allow them to assure that every state and territory has a full complement of programs addressing these challenges to our health.

State Chronic Disease Directors and the State Health Agencies where they work have a unique role in coordinating activity and steering resources to communities most in need and creating linkages across systems with healthcare providers, insurers, educators, community organizations, and others. States effectively maximize federal investments and ensure the most efficient mobilization of local organizations, while at the same time avoiding any duplication.

The minimal investment in chronic disease prevention and control at CDC, state and community-based programs supported through CDC, and states has resulted in developing an extensive portfolio of strategies that work. With current financial resources these programs are not scalable across the nation. This is the largest barrier we are facing in regards to preventing expensive chronic diseases.

The federal investment needs to be such that every state has a cadre of evidence based programs to fight chronic disease including:

• Early Detection of Cancer and Cancer Survivorship Services
• Diabetes Prevention and Control (including prevention of related kidney disease)
• Heart Disease and Stroke Prevention
• Healthy Community Programs (REACH, others)
• Tobacco Prevention and Control
• Alzheimer’s Disease Program (Healthy Brain Initiative)
• Arthritis Prevention and Control
• School Health and Oral Health Programs
• Post-Covid19 Chronic Conditions

The Ethical Dilemma

America is on the precipice of great challenges and great opportunities; we need to invest in a meaningful way in prevention now before it is too late, and we are too ill to invest. The place to start is at CDC, with the state- based programs reaching localities across the country as mentioned above. The bioethics principle of justice calls for fairness, resource allocations are currently anything but fair. The bioethics principle of autonomy calls for respecting the informed decisions of individuals. These decisions cannot be fully informed without public health programs to educate populations (especially those at greatest risk). The ethical principle of beneficence calls us to “do good”. We know that these strategies can make a difference we need to support them to be beneficent. Finally, the principle of non- maleficence more commonly known as “do no harm” requires that we act on our knowledge to avoid the predictable harm that is occurring and will only increase without these investments.

In case there is remaining doubt, Trust for America’s Health reported the return on investment for public health prevention programs is 0.96:1 in years one and two and 5.6:1 by year five. This means that even in the initial budget period there would be a net gain by investing in prevention.

Public health programs improve care, prevent disease, and prevent complications of disease. An investment in chronic disease prevention and control programs saves lives, improves quality of life, and saves healthcare dollars.