ADVICE FOR THE NEXT PRESIDENT

Some six thousand years ago, the Yellow Emperors’ Classic on Medicine advised that doctors should be paid only when their patients remained healthy. By these standards most U.S. physicians would be bankrupt.

Every presidential candidate understands that our nation cannot continue to stand alone in the industrial world for its failure to provide medical care to our citizens. But there is one issue that few dare acknowledge: we have to find a way to reduce the total costs of health care – more than $3 trillion and rising – no matter how efficient we may become at providing it. Nowhere is the need to lower costs by preventing disease more evident than in the growing toll of cancer on our society, which runs $100 billion each year for treatment alone. We must make prevention the cure for the mounting toll of cancer.

America spends nearly 15% of its gross domestic product taking care of the sick--double the proportion of twenty years ago. Yet, we still rank 21st in the world in terms of outcomes. Remarkably, just 2% of the GDP is devoted to environmental protection, and ever-declining amounts are spent studying and identifying controllable environmental risks by flagship institutions like the National Institutes of Environmental Health Sciences. Budgets for federal environmental protection are at an all-time low. Granting universal health care to the uninsured millions, without providing access to good nutrition, safer workplaces, cleaner air and households, will increase spending for health care but not improve public health. We cannot spend infinite resources on infinite health.

The best way to ensure that people don’t die of cancer is to take away those things that we know or suspect cause disease. While we have finally made some progress on tobacco, other well-known cancer hazards—like asbestos and benzene—remain poorly controlled.

Preventing cancer should not be confused with providing mammograms or colonoscopies to millions. When properly applied to middle-aged people, these technologies can save lives—a phenomenon already evident in the reduced deaths from these cancers.

Indeed, as recent recalls of the widely used medications Heparin and Vioxx make clear, the system for monitoring adverse impacts of drugs is broken. Too often we have followed a drug policy of shoot, ready, aim. Within two years, the radical drop in using hormone replacement therapy to treat the ‘disease’ of aging in women—something the late Barbara Seaman first warned against more than three decades ago—appears to have staved the growing rates of breast cancer in older women.

Soon, we will not have enough surgeons and oncologists to treat the growing numbers of cancers that will occur as more of us reach old age with four times more cancer than occurs in Japan. Growing disparities in cancer for blacks do not reflect changes in our genes. Instead, they arise from complex ways that the environment affects the genes with which we are all born. Conventional thinking chalks this disparity up to the fact that blacks are generally diagnosed with more advanced disease. Could their greater chances of dying of cancer have anything to do with the fact that while one in eight Americans is black, two to three times more African-Americans work and live in more polluted environments than do whites?

What about young people today? Why are more young men developing testicular cancer? Why are rates of acoustic neuroma, a benign tumor of the brain, growing throughout the modern world? A recent study by the National Cancer Institute notes that children who receive radiation treatment face increased rates of this tumor as young adults. One in three young women who survive radiation to treat Hodgkin’s disease as teenagers will develop breast cancer by the time she reaches age forty. Almost half of women who develop mesethelioma—a crippling suffocating tumor once thought to be uniquely tied to asbestos exposure—have never worked with asbestos.

Most cancer is not born, but made, arising as a result of myriad things that happen to us throughout our lives. Identical twins do not get the same cancer. Within two generations, persons who migrate to America or Scandinavia from Asia tend to acquire the risk of cancer of their new country. Cancer rates not tied to smoking have grown by 50% in blacks and whites.

These changes in cancer patterns provide stunning clues. They make it clear that prevention remains the best cure for cancer. We can start by joining the rest of the industrial world on three major fronts. Like growing numbers of modern nations, including Uruguay and Italy, we need a national ban on smoking in public places. We also need a serious public campaign to identify, control or get rid of asbestos—now projected to be in 35 million American homes in the form of zonolite insulation, and we should join the rest of the industrial world and ban asbestos altogether. Finally, we should make a national commitment to expanding our right to know about hazards. Like the European Union, we should find and control workplace, household, radiation and other carcinogen exposures in order to reduce the mounting demand for cancer treatment.