One of my least favorite public health organizations is the United States Preventive Services Task Force, the USPSTF for short. I’ve written about them before (“Is the USPSTF doing the public a disservice?”) criticizing their de-emphasis on some screenings calling them not “cost effective” or showing “no evidence of benefit.” Some physicians consider their recommendations as gospel, but to my way of thinking their positions generate more confusion and controversy than any other professional organization. In many cases, they discourage procedures that have widespread public acceptance.
The American Academy of Family Physicians (AAFP) recently published an extensive article outlining recommendations for Adult Preventive Health Care. These are screenings and preventive therapies the USPSTF feels are important for adults age 18-80. Included, also, are the recommended intervals and frequency of screenings.
Nowhere in the list of 28 recommendations is it mentioned that a patient needs to be examined by a doctor. It seems that with all of today’s technologic advances, the physical examination is passé and has lost its role in healthcare. After all, why examine someone’s lungs if you’re going to screen them for lung cancer with a CT scan anyway?
Additionally, eleven of the 28 recommendations are for conditions caused by behavioral indiscretions or lifestyle choices. These are problems the majority of Americans, except those who ignore the risks, don’t have. At the risk of moralizing or sounding judgmental, these 11 problems could be avoided altogether by avoidance of those behaviors. Yes, I know some people have diseases that are caused by the bad behavior of someone else, such as the unsuspecting, innocent patient who develops Hepatitis B from receiving tainted blood. Someone else’s bad behavior results in severe consequences for someone else.
Again, at the risk of moralizing, it would appear that the USPSTF thinks all Americans are sexually promiscuous, practice risky behaviors, live with an abusive partner, or are gluttonous. Many recommendations (11 of 28) are made because people make bad health choices or live a lifestyle that exposes them to disastrous health situations. Screening for these problems is important, of course, but a strong statement identifying the behaviors to avoid would be equally helpful.
What follows is a list of the problems for which screening procedures are recommended that could be eliminated by altered behavior. However, little or no mention is made of the behavioral alterations one could make to prevent acquiring these conditions. In a “perfect world,” none of these problems would exist because “risky behaviors” would not be practiced. These problems are:
- Alcohol “misuse”—solution: responsible drinking, limited intake
- Obesity—overeating, improper dietary habits
- Tobacco use—overuse is associated with COPD, CVD, lung cancer—somewhat preventable diseases
- Hepatitis C virus infection—acquired by IV drug use (60%), sharing needles, unprotected sex with Hep C carrier (15%), accidental needle stick (5%), tainted blood transfusion (10%).
Behavior changes eliminate 75-85% of Hep C.
5. HIV infection—male-to-male unprotected sexual contact (81%), IV drug use (5%), both
male sex/IV drug use (4%), heterosexual sexual contact (9%). Behavioral disease.
6. Hepatitis B virus infection—transmission similar to Hepatitis C—multiple sexual partners, IV
drug use, shared needles. Behavioral disease.
7. Syphilis—a sexually transmitted disease, promiscuity increases risk. A behavioral disease
8. Gonorrhea, Chlamydia—sexually transmitted disease, promiscuity.
9. Intimate Partner Violence—severe social disorder of behavioral origin.
10. Human Papilloma Virus (HPV)—a sexually transmitted virus that causes cervical cancer.
Sexual promiscuity causes transmission of virus.
11. Skin cancer prevention—refusal to use sunscreen causes skin cancers.
In their recommendations, the USPSTF omits any mention of remedies or preventive measures for these disorders. Nowhere do they mention avoidance of the behaviors that result in these problems. That would be judgmental. Alcohol abuse, obesity, tobacco use, and diabetes are worthy of “behavioral interventions” or “intensive counseling,” but Hep B, C, HIV, syphilis, gonorrhea, chlamydia, and “intimate partner violence” receive no mention of actions the patient could take to avoid these problems.
Other diseases such as diabetes, colorectal cancer, breast cancer, hypertension, tuberculosis, hypercholesterolemia, depression, and lung cancer, for which screening recommendations are also published, are either genetically mediated or not always caused by lifestyle choices. Changes to our bodies occur that are out of our control or are unexplainable. These problems develop outside of our control. Other than obesity, these diseases are far more common among the general population than most “behavior-related” diseases.
Patients hide many behavioral disorders making screening for them more important for public health. However, you cannot test for HIV, Syphilis, or Hep C, etc. without first informing the patient. They must either request the test or consent to it before its done. Random, indiscriminate screening is not permissible. Appropriate questioning by the provider, though, can uncover issues for which testing can be suggested, but the patient must still consent.
Armed with screening test results, the health care provider now has the opportunity to educate the patient on changing behavior to prevent these problems, but the USPSTF refuses to take such a position or offer that advice. Instead, they treat these conditions as “mainstream diseases” and make it seem like they’re a fact of life that everyone is likely to experience. That’s just not the case. If one doesn’t engage in these “risky behaviors,” diseases such as syphilis, Hepatitis B and C, and HIV don’t occur.
To my way of thinking, their emphasis is misplaced. The USPSTF, needs to recommend screenings, but also stress that these are preventable diseases and offer solutions for them. If they (USPSTF) would ever come to that realization and make such a statement, it will be a remarkable step forward. But in today’s world that will never happen.
References: Adult Preventive Health Care Schedule: Recommendations from the USPSTF. www.aafp.org/afp 2020 Sep 21.
