AMA Journal of Ethics^®

Dr. Gro Harlem Brundtland, director-general of the World Health Organization (WHO), has handed down an ominous warning: "the world is living dangerously, either because it has little choice or because it is making the wrong choices about consumption and activity."¹

With this warning came a list of the top 10 threats to health worldwide and a plea for decisive governmental action.

The top 10 threats to health are:

1. underweight
2. unsafe sex
3. high blood pressure
4. tobacco consumption
5. alcohol consumption
6. unsafe water, sanitation, and hygiene
7. iron deficiency
8. indoor smoke from solid fuels
9. high cholesterol
10. obesity

And the plea goes something like this: "Harness the forces of globalization to reduce inequity, to diminish hunger, and to improve health in a more just and inclusive global society."¹ Notice that from a policy standpoint, reducing the risks to health on this list requires equitable distribution of the world's resources before medical intervention.

The WHO is calling for government action and large-scale reforms such as higher taxes on tobacco, population-wide educational campaigns on obesity and cholesterol, and AIDS education in schools.¹ They ask governments and other organizations to pursue "preventing the actual causes of important diseases as well as treating the diseases themselves."² Some of the WHO's recommendations such as reducing salt content in processed foods have been met with support. The American Public Health Association (APHA) recently came out in favor of this action, saying it could save 150,000 lives a year currently lost due to strokes, heart attacks, and other illnesses linked to high blood pressure.³ The Institute of Medicine (IOM) wants increased spending on public health and public health education. It is pushing for all medical students to receive basic public health and preventive medicine training.⁴ But what the WHO, the IOM, and the APHA are all advocating for, though from different angles, is preventive medicine. The medical community needs to adopt a new approach to achieving patient wellness.

Now look at the list again. There is a sad irony which this lists highlights, the "gap between the haves and have-nots."¹ But the WHO "haves" and "have-nots" are not the traditional wealthy and poor. This report splits the world into those who have no health choices, and those who have choices about their health and make the wrong ones. Most people in the United States fall into the latter category.

So what wrong choices are we Americans making?
Too much alcohol; too much tabacco.
High blood pressure, high cholesterol.
Obesity.

Do these suggest greed?
Sloth?
Gluttony?

All Americans, citizens of an economic superpower though they may be, need to do some serious rethinking about their lifestyles. Among industrialized nations the United States spends the highest percentage of its gross national product on health care, and yet the WHO ranks the US system 37th in an assessment of global health systems.⁵ As much as 95 percent of US spending on health care goes toward biomedical research and medical care⁵ while as little as 1 to 2 percent is spent on preventive medicine.⁴

There is no question that government reforms, public campaigns, and an overhaul of the public health system would go a long way toward eliminating health risks, but it might take a long time. Making preventive medicine a priority doesn't have to mean political red tape and lobbying; there is a grassroots approach. It can start with each doctor treating his or her own population of patients with preventive medicine in mind. Patient education before serious health conditions arise is a good starting point. It means discussing a reasonable postpartum weight-loss program with your patient who is in her third trimester of pregnancy; talking to your recently divorced, middle-aged patient about healthy stress relief and a low-salt diet before his blood pressure skyrockets. It means recounting the dangers of smoking and the monetary savings of quitting to your smoker-patients rather than just checking the box marked, "Smoker, Yes." It means standing on your soapbox of healthy living with all your patients.

The WHO's plea to governments around the world "to take bold and determined actions against a relatively few major risks to health, in the knowledge that the likely result within the next 10 years will be large gains in healthy life expectancy of their citizens," is a challenge that can be taken up by all practicing doctors in the interest of the health of their patients. But it is more than a challenge to improve the health of your patients, it is a challenge to the doctors' way of thinking. To practice preventative medicine, physicians have to give up the historically and culturally grounded view of the profession as healers of disease and adopt a view of their jobs as preservers of health. For both physicians and patients this means taking a proactive interest in their health rather responding reactively to illness.