Across an expanse of roughly 40 years of personal effort, I can, alas, affirm the common knowledge. More often than not, these windows reside on the far side of calamity, the aftermath of stroke, or heart attack; endocarditis ravaging heart valves, emphysema devastating lungs. There are happy exceptions- pregnancy stands out. But for the most part, people acquire a zeal to invest in their health once they have, to one degree or another, lost it.
This matters for reasons as indelible as nursery rhyme. Despite all our technology, the scope of the modern pharmacopeia- we really are no better still than “all the king’s horses and all the king’s men.” We still can’t uncrack a shell, to say nothing of unscrambling the egg. More prosaically, the diverse “we” constituting the full prowess of modern medicine have little capacity to confer full, fulsome vitality once it has been ransacked.
If anything, that rather understates the liabilities of “ex post facto” prevention. The exigencies that follow any given medical misfortune invite remediations prone to reverberate into contingent damages and discomforts. The drugs used to treat the recent heart attack or stroke, and prevent its recurrence, might, for instance, induce a gastrointestinal bleed. Drugs used to lower lipids might induce diabetes. And so on. Richly informed as we are by the follies of history, we may conclude with some confidence that despite their current luster, the GLP-1 agonists are unlikely to depart far from this narrative.
Of course, these contingent liabilities do not pertain to lifestyle as medicine, one among the many reasons some of us are ardent champions of it. But even in that domain of rarefied promise, we would much prefer to protect health from a fall off a high wall than endeavor to patch it up afterward.
These reflections on missed opportunity come to their apotheosis in the context of intensive care. Every ICU is an incubator of cascading disaster, as the failure of any given organ system induces the failure of another. We humans are, absent the bonds of vitality that hold our parts robustly together, a house of cards.
In the ICU, where many among the greatest wonders of modern medicine are plied, only bad options prevail. The most potent of drugs are, inevitably, also the most toxic. The desperate needs of unoxygenated lungs come at the expense of the overburdened heart; those of that heart, at the expense of kidneys; those of the kidneys, at those of the lungs- and so on. I have seen, from the vantage of both the professional and the familial, those terrible impasses where all the might of modern medicine is stymied by multi-organ-system failure; where the only recourse is to tread gently along a knife edge of dreadful choices, to wait and hope the body heals.
That, then, is my intended message here: intensive care is the realm of bad options. As, too, is war.
My provocation for this column is not a patient in the ICU - that was part of my purview for decades, but no more - but rather the comparably horrible quagmire of geopolitics in the Middle East. Bodies, and the body politic, share noteworthy traits. The recurring failure to traffic in the ounces of prevention no matter how great the weight of cure is salient among these. So, too, is its consequence: only bad choices in the crucible of calamity.
In response to the ghastly Hamas/Israel war currently reverberating through regions, religions, rationales, hearts, and minds around the globe- a great trove has been said. Much of it born of genuine passion; as much or more likely born of propaganda and pernicious motives. Such is the price we pay for the agency of electrons and the instantaneous delivery of every exhortation to everyone, everywhere, all at once.
I don’t presume to append to all this. Those inclined to seek can find ample words to suit their yearnings, words of compassion and conviction, insight and indictment. We have heard the poignant and the penitent; the desperate and the daring; the courageous and outrageous and outraged. Words have been used to blame this and excuse that, blame that and excuse this; to vilify, vituperate, and vindicate. More words directed here seem unlikely to add more light than heat.
Hope resides, perhaps, if anywhere, where words disperse into pictures for the mind’s eye; where the critical insight is refracted by the prism of metaphor. Where wars that can be lost but not won are perceived as the plight of failing organ systems with competing desperations for intensive care.
Prevention was the only good choice. All the rest are ghastly, and no amount of shouting about that bad choice makes this bad choice any better.
What, if any, good could come of this when the current round of shouting is done and the horrible costs are tallied?
Maybe none. What a sad indictment that would be of our disinterest in listening for valid convictions we don’t already own, in the will to change our worst ways.
Maybe, though, there can be one crisis too many; one too many bereaved parents, one too many lost sons or daughters. Maybe there comes a time when the wages of cure finally invite the rebellion of prevention. The wait has been long.
In medicine, I hold out hope that the value proposition of health may yet prevail. Health is not the moral imperative our culture makes it out to be; health is not a message best delivered at the wag of an admonishing finger. Other things being equal, healthy people have more fun. Health enables you. Health is a relevant currency wherever opportunity is on sale.
How great the blessings we might enjoy- more years in life, more life in years, for ourselves and those we love- if health were merely something we valued enough to invest in with dedication before, instead of after some disaster.
We have guidance in this area, from many sources. Noteworthy among them is the U.S. Preventive Services Task Force. One could say such guidance is about counterfactuals, the alternative realities that branch from a decision node. The art and science of prevention, and the evidence that underlies these, are really all about gauging the difference in probable outcomes after making a given choice, and taking a given action.
Were the power in such projections to marry to a culture-wide reverence for health approximating our attitudes about wealth, what a world of opportunity would unfold. Good choices would prevail.
I can’t help but imagine the analogous authority, devoted to the systematic study of geopolitical disasters, issuing evidence-based recommendations for preventing the next occurrence. That, wed to a culture-wide reverence for our common humanity would, as well, evince a whole new world of opportunity.
I am not holding my breath. Hope is embarrassingly naïve. But where are we without it? At this seasonal reminder to elevate our gratitudes (a good Thanksgiving to all), I am thankful for the perennial triumph of naïve hope over jaded experience.
Critical conditions and dire prognoses beget bad choices for our bodies and the body politic alike. No amount of shouting at one another, of seeing separate parts of a common whole, will turn any of these choices good. Sometimes, the greatest gift the present can tender is understanding; sometimes, overcoming is unavoidably deferred.
Calamity incubates only the grimmest of choices. But we do have the choice to heed the teachable moment, anticipate and prevent the next catastrophe. Sometimes the one best hope we have is something left to hope for.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.