We All Want Longer, Healthier Lives. But It's Going to Cost Us.

Then there's prevention, a favorite money-saving ace in the hole. The trouble is that prevention also costs money. A study that got front-page coverage nationwide in the week after the election not only demonstrates that but also shows how much we value small improvements in health. A group of researchers in Boston found that if you prescribe cholesterol-lowering drugs to people whose cholesterol levels are normal but who have evidence of mild body-wide inflammation, you can reduce their chances of developing cardiovascular disease by about half. "It's a breakthrough study," effused the head of cardiology at the Cleveland Clinic. "These are findings that are really going to impact the practice of cardiology in this country," said the head of the National Heart, Lung and Blood Institute at the National Institutes of Health.

What few stories pointed out was how little bang you actually get for this prevention buck. You have to treat 95 people for two years to prevent one "event" -- death, heart attack, stroke. At a cost of up to $1,200 a year for the drug, Crestor, that's a big investment to make year after year to help a few people. Given the response to the study, however, I suspect it's an investment we'll soon start making routinely.

Furthermore, there's little evidence that preventing disease reduces health care costs over the long run, although it obviously extends lives and prevents misery.

So what's likely to happen?

Over the short term, many experts say, there will be the sort of adjustments that humans make whenever necessities -- food, heat, shelter -- become scarce. We'll pay more for health care. We'll give up small things in favor of it. We'll cut corners. We'll complain. And then we'll find other corners to cut and reluctantly pay still more. Of course, the "we" may not include all of us; some Americans pay little or nothing for their health care. But as a society, we'll all pay more.

In the longer term, however, not just the United States but the entire industrialized world is facing a conundrum resembling a famous one of 200 years ago. In 1798, an English parson named Thomas Malthus published "An Essay on the Principle of Population as It Affects the Future Improvement of Society." He laid out a chilling scenario in which population growth outstrips food production and produces a cycle of famine, catastrophic population decline, recovery, famine and catastrophic decline, over and over.

This was the so-called Malthusian Spectre. It was a hugely influential -- and horribly frightening -- idea. It kept members of Parliament awake at night. But it never came to pass because of two as-yet-undiscovered truths that Malthus never imagined.

The first was that scientific agriculture would eventually double, triple and quintuple crop yields. The second was that when industrialization pulled huge numbers of people out of poverty, infant mortality fell, women became more educated, and the value of their labor rose. The net result was a huge decline in birth rates. This is known as the "demographic transition," and virtually every region of the planet has gone through it.

We will need something like the revolution of scientific agriculture and the demographic transition to rescue us from the Malthusian Spectre of health care spending.

What it might be -- ah, that's what nobody knows.

browndm@washpost.com

David Brown is a medical doctor and a health and science reporter for The Washington Post.