The Cost of Success

If a program is successful, you should end it. Correct?

That's why the CDC may be gutting Massachusetts' HIV prevention programs. Infection rates are lower in the Northeast than they are in many other parts of the country, and the CDC wants to improve prevention services in places with higher infection rates. Sounds reasonable, but it could have an effect exactly the reverse of the intention.

So what does the CDC do when they find that they've caused the rate of infection in the Northeast to go up to match the rest of the country? That's what could happen, since each program has a measurable impact on the HIV infection rate.

Many prevention programs begin as a research program or a local pilot. Success means that the people who were part of the program had a lower HIV infection rate than a comparable population. Let's use a HIV prevention hotline as a possible pilot. Start by opening it to one region, then look at the infection rate both before and after the hotline opened in that region, and also compared to other regions. If the infection rate went down relative to other regions, that hotline is a success. It then gets rolled out to everyone.

Each program is based on being able to reduce the rate of HIV infection by some percentage. Commonly, the goal is 5%. It doesn't sound like a huge amount, but absolutely worth it when you consider how many people that 5% represents.

The important thing is that the rate of HIV infection is lower while the program is active. What happens when it's no longer active? What happens when five programs, each of which has shown to be able to reduce infections by 5%, are cancelled?

Addressing the higher rate of HIV infection in some areas of the country is an absolute priority. That's another topic to go into later. But here's a hint: once a successful program is gone, so are the people who can help new programs be modeled on it.

Prevention Is a Hard Sell

The latest report to be issued on the state of health in Massachusetts just came out. If you want the details, the Globe did a writeup that covers some of the key points. There are many areas in which the Commonwealth is doing well, and many areas sorely lacking, but ultimately it all comes down to the money.

According to the report, Massachusetts spends $63 billion on medical services and $600 million on public health (which includes prevention). So in total, the amount that we spend to prevent medical issues is less than 1% the amount that we spend to treat them after they occur. Due to the Commonwealth's tight budget, the relative percentage has actually gone down over the past few years.

What might happen if you doubled the amount spent on prevention, so that it's maybe up to somewhere around 2% of the money we spend on treatment? Over time, the population will be healthier and expenditures on treatment of preventable illnesses will go down.

For example, take Codman Square in Dorchester. There's no supermarket there, but there is a fast food restaurant. There are some parks where people can exercise, but they're not always safe so many people don't. Some money to bring in fresh, healthy food and make the streets and parks safe would be a great way to make the people of Codman Square healthier. In particular, the rate of obesity and diabetes might go down.

Now, prove that there's a return on the investment. How exactly would I show that those people who now don't have diabetes would have developed diabetes if that money hadn't been spent? There are very few feasible ways to do it. How would you prove that something that could have happened didn't due to something that you did?

The thinking about prevention is completely backwards. Why isn't improved health an outcome worth funding? Instead of looking at health as an absence of disease, why not think of it as a presence of proper body and mind function? The return on investment will come, but it will really be from the increased productivity of healthy people and not from an illness that didn't happen.