Mayo Clinic Preventive Medicine and Public Health Board Review

Johnson, Anne

Hardy, Anne

Everyone knows the old adage, "an ounce of prevention is worth a pound of cure," but we seem not to live by it. In the Western world's health care it is commonly observed that prevention is underfunded while treatment attracts greater overall priority. This book explores this observation by examining the actual spending on prevention, the history of health policies and structural features that affect prevention's apparent relative lack of emphasis, the values that may justify priority for treatment or for prevention, and the religious and cultural traditions that have shaped the moral relationship between these two types of care. <p/>Economists, scholars of public health and preventive medicine, philosophers, lawyers, and religious ethicists contribute specific sophisticated discussions. Their descriptions and claims lean in various directions and are often surprising. For example, the imbalance between prevention and treatment may not be as great as is often thought, and we may be spending excessively on many preventive measures just as we do on treatments compelled by the felt demands of rescue. A standard practice in health economics that disadvantages prevention, "discounting" the value of future lives, may rest on weak empirical and moral grounds. And it is an "apocalyptic" religious tradition (Seventh-day Adventism) whose members have put some of the strongest and most effective priority on long-term prevention. <p/>Prevention vs. Treatment is distinctive in carefully clarifying the nature of the empirical and moral debates about the proper balance of prevention and treatment&#x3b; the book pursues those debates from a wide range of perspectives, many not often heard from in health policy.<br>

Available

Viral Vaccines Joseph L. Melnick As with history in general, the history of vaccines needs to be reexamined and updated. My task is to look back to see what has been successful and to look forward to see what remains to be accomplished in the prevention of viral diseases by vaccines. Also, I shall refer to the pertinent material discussed at two recent conferences of the Institute of Medicine, National Academy of Sciences, on virus vaccines under development and their target populations in the United States (1985b) and in developing countries (1986). These reports, plus a third on Vaccine Supply and Innovation (1985a), should be required reading for all those in both the public and the private sector who have a responsibility or interest in vaccines for the prevention of human disease. It has been through the development and use of vaccines that many viral diseases have been brought under control. The vaccines consist either of infectious living attenu- ated viruses or of noninfectious killed viruses or subviral antigens. When we look at the record, it is the live vaccines that have given the great successes in controlling diseases around the world. Examples are smallpox, yellow fever, poliomyelitis, measles, mumps, and rubella.

The discovery of the human T cell leukemia virus type I in the late 1970s heralded a new era in retrovirology. For the first time, it was demonstrated that a retrovirus could play a role in the development of a human disease, in this case adult T cell leukemia (ATL). Several years later, the acquired immunodeficiency syndrome (AIDS) epidemic began, and it was dem- strated that a retrovirus, originally designated the human T cell lymp- tropic virus type 3, was the causal agent of this syndrome. This virus, later named the human immunodeficiency virus type 1 (HIV-1), has since been extensively studied in terms of its pathogenesis as well as its ability to elicit immune responses. In that time, a tremendous amount of information has been obtained about the virus. Although recent drug regimens have been useful in significantly lowering viral loads and perhaps maintaining an asymptomatic state among individuals infected with HIV-1, an established "cure" for AIDS eludes us. In addition, the effective drug therapies are very expensive, and are not available to infected people in the third world, where greater than 90% of new infections occur. Furthermore, the development of viral resistance against the drug therapies is an additional concern. Despite extensive study, no effective vaccine has been developed. One of the problems in developing an effective vaccine against HIV-1 is the ability of the virus, particularly in the immunogenic envelop glycoprotein, to undergo amino acid hypervariability.