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[ JBEM Index / Volume 2 / Number 2 ]

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How Would God Have Us Practice Preventive Medicine?

Dr. Terrell is Assistant Professor of Family Medicine at McLeod Regional Medical Center in Florence, S.C.

Preventive medicine is widely popular today. The government hopes through it to solve its rising health care bill. Private industry, which pays the bulk of health insurance premiums, has the same hopes. Physicians are finding in the popular concept an opportunity to protect their incomes while in good conscience protecting their patients' health. Christians are proponents of it because it seems to fit so well biblical admonitions such as I Cor. 3:16,17. In a world in which we must be against so many things, in this one area, at least, Christians don't have to be at odds with a popular movement.

While we don't have to be at odds with the intentions of health maintenance (another title by which preventive medicine travels), a close look turns up some problems that need addressing. The problem addressed in this article is the built-in presumption that prevention is primarily a task of the medical profession. It is not. Related problems, which will be touched but not dealt with in detail, include the fact that the popularity of prevention in medicine has outpaced ability of the profession to deliver it and the assumption that preventive medicine offers a substantial solution to rising medical costs (it doesn't).

Before examining the problems, it is necessary to assert that preventive medicine is an idea thoroughly consistent with scripture. God has granted life and He requires that we be good stewards of each life. God is "pro-life"! Each human being bears His image. Though the image is not our physical appearance, we are to honor God's image in all people by supporting their life and refusing to take innocent life. The answer to the Larger Catechism question #136 includes preservation of life under the sins forbidden in the sixth commandment: "... the neglecting or withdrawing the lawful or necessary means of preservation of life; ..immoderate use of meat, drink, labor, and recreation, provoking words, oppression, quarreling, striking, wounding, and whatsoever else tends to the destruction of the life of any." Obedience to the sixth commandment is more fully accomplished by godly living than it is in preventive medicine (as it is presently conceived).1

First Timothy 4:8 is often quoted by Christians as an entry point for technical knowledge of prevention. "For physical training is of some value, but godliness has value for all things, holding promise for both the present life and the life to come." Note that godliness not only has promise for the life to come, but also.for the present life. The thrust of the verse is not to point to the virtue of physical exercise or all that it may imply, but to use it as a contrast to something which is really valuable - godliness. An application of the verse today might be as follows: a pretraining stress ECG for a middle-aged man is of some value, but if you really want value now (physically) and in the hereafter, be exercised in godliness.

Another frequently cited point of contact between scripture and medicine is 1 Cor. 3:16,17: "Don't you know that you are God's temple, and that God's Spirit dwells in you? If anyone destroys God's temple, God will destroy him, because God's temple is holy (and you are that temple)."

Medicine can certainly teach us something about body maintenance, yet it is godliness that has the most to do with the maintenance. Somehow, things have gotten turned around. Christians routinely seek physicians' advice on health maintenance while remaining heedless of ungodliness in their lives. Christian physicians routinely bypass obvious ungodly behavior which has possible adverse health consequences in their patients - a quick temper, unforgiven sin, unconfessed guilt, etc. We don't even think of these as health issues, or, we put them aside as "not in our field." After all, we weren't called to preach. I have kept problem lists on my patients for years, diligently noting down Congestive Heart Failure and such. Never have I entered "Quarrelsomeness" on one, despite the fact that I have treated many patients whose quarrelsomeness earned them injury.

There are practical reasons for not writing "spiritual" problems in the medical record. The record exists partly to communicate with other physicians and some would not understand. There is no code, for instance, for "gossip" in the International Classification of Health Problems in Primary Care (ICHPPC). Insurors would refuse to honor their contracts with patients who submitted a claim with such a "diagnosis" on it, not to mention that patients wouldn't take kindly to it. We can excuse ourselves for not writing it, but we have a serious problem if as Bible-believing Christians we can't even think of it as a health maintenance issue, or that it is remediable.

As for not being called to preach, check yourself out, if you are a physician. Chances are you have a spiel on some practice that damages health obesity, smoking, failure to use seat belts, etc. It is not our reluctance to preach that holds us back but our habit of sticking to the material aspects of the world for our subject matter. This insistence on addressing only physical issues has been inculcated in us by the humanist worldview. In a biblical worldview the material aspects of our being are important but not ascendant over the spiritual aspects. We are commanded by Jesus to disciple others. He has not exempted our medical practices and we should not allow our unconscious adoption of a humanist value to prohibit us from wise use of opportunities to make a spiritual connection for our patients to consider.

A young man I have known for several years came to the Emergency Room. A professing Christian, he has a quick, hot temper. I had noted it before but never mentioned it. This night he had received the worst of it in a fight which included a knife in the other fellow's hand. I sewed him up with nylon monofilament. I still did not address the temper. I was acting in faith that my nylon stitches would help the knife cut mend. I introduce the nylon into his flesh but abstain from introducing applicable scripture to his spirit for spiritual healing and the physical health consequences which could result. Thus I practice 1 Tim. 4:8 backwards; it comes out something like this: "For godliness is of some value but physical treatments - that is where the real power is!" I certainly believe that the Holy Spirit acting through the Word can mend the young man's quick temper which led to the knife fight. I know that he is under the oversight of a church, but I didn't refer him to them for their help in dealing with the real root of his "medical" problem. When I practice this way, I practice as though I believe medicine is a secular art, isolated from a person's spirit.

Preventive Parenting

"Parenting" is in vogue. It is not usually discussed in the context of health, however. The thrust is usually to develop a child's innate potential and to avoid such future disciplinary problems as truancy or delinquency. Eph. 6:1-3 states, "Children, obey your parents in the Lord, for this is right. Honor your father and mother; - which is the first commandment with a promise - that it may go well with you and that you may enjoy long life on the earth."

Parents are thus accorded substantial health maintenance power, whereas physicians find no such encouragement. In fact, some common medical practices actually work against this parental health maintenance power.

As an example, in my own specialty of family medicine, Christian physicians sometimes adopt from humanists a misbegotten elevation of patient confidentiality over parental authority. The argument goes, "If I don't promise confidentiality to my older minor patients, they won't divulge to me the information I need to treat them. It may even cost their life." Which is more important for the overall health of children, that physicians thus encourage secrets to be kept from those responsible for them or that parents have access to information they need to fulfill their responsibility to their children? "But they sometimes don't fulfill their responsibility," is the rejoinder. Is that sufficient reason to steal it?

Because of this commandment connecting longevity with parental authority, substantial ground would be necessary to overturn parental responsibility in the name of health. "Confidentiality" is insufficient ground. Where God has assigned responsibility, He has granted authority to be privy to pertinent information. Given that God has granted the responsibility to parents, we can scarcely hold up to Him our need to keep from parents the very information they need to fulfill their responsibility.

Before we criticize parents who seem to have abdicated their responsibility, we need to seek them out and confront them with God's word on the matter. "We haven't time to do that. They are often literally absentee parents and hard to locate." Just how hard have we tried? Meanwhile, to promise dependent minor patients at the outset that we will hold what they tell us in confidence from their parents is to prejudge the parents and to encourage children to disobey the commandment. A more fitting confidentiality position with minors and, indeed, all patients, is: "I promise not to tell what I know about you to anyone who does not have a God-given right and need to know it."

Pastors who teach their flock God's law should accurately consider themselves to be promoting preventive medicine when teaching "parenting" skills from scripture. The number of medical contacts resulting from unbiblical parent-child relationships is large, including preventable accidents, drug abuse, venereal disease, functional abdominal pains, tension headaches, illegitimate pregnancy and more. Small children whose parents tolerate "sass" or disobedience, as in a church nursery, can be provided inexpensive, powerful health maintenance without physician involvement. The elders can admonish the parents on the fifth commandment and its applicability in the present life and in the life to come.

Figure 1 is an estimate of the impact of deaths from selected causes.' The graph shows the maximum number of years of life which could be spared if all of the deaths from these causes could be prevented. Medicine has developed imperfect but defensible techniques to prevent deaths from cancer of the cervix and from cancer of the colon. Among the young, accidental death, suicide and homicide are leading causes of death. Because the young are farther removed from the end of their natural life span, a youthful death deducts more years of potential life. Any technique which reduced the violent deaths of the young would be, therefore, much more powerful than one close to the end of a natural life span.

These violent forms of death thus account for a disproportionate amount of premature death. They are largely related to a person's lifestyle. Even if parenting, discipling and preaching are not very effective, saving only a small percentage of people from adopting death-styles in their youth, they can nonetheless save more years of human life than some of the health maintenance tools used by medicine. Even if the ministry of a church deterred only 1 % of young people from carelessness, despair or aggression, it would be more life-preserving than Pap smears. Pastors and parents need not defer to the medical profession as the only experts in health maintenance.

Marriage as Health Maintenance

Marriage is positively related to life expectancy, through the medium of lower incidence of diseases such as cancer.' While much disputed, there are indications that marriage, per se, is protective, not merely that people with poor health habits or pre-existing health problems are less likely to become or remain married.4 Do ministers who preach God's word on marriage regard their sermons as preventive medicine? Do they advocate marriage for those who do not have the gift of celibacy? If not, why not? Parents who demonstrate a good marriage and promote marriage before their children are practicing preventive medicine. Are they aware of this? They should be told by their pastor and their physician. The potency of the marriage-health connection exceeds many preventive medicine tactics the medical profession uses. Keeping of the seventh commandment in its fullness would eliminate all venereal disease within a generation. The medical profession offers the material solution of the condom. It is ludicrous in comparison.

Work as Preventive Medicine

We hear much of the connection disease has with poverty, yet we somehow do not connect biblical admonitions to work with preventive medicine. Lack of money is connected with early death, and not primarily through lack of access to medical care due to lack of money.' Despite government erosion of the connection, poverty is still substantially connected in our nation with the work ethic. Eph. 4:28 says, "He who has been stealing must steal no longer, but must work, doing something useful with his own hands, that he may have something to share with those in need." Second Corinthians 8:13-15 says, "Our desire is not that others might be relieved while you are hard pressed, but that there might be equality. At the present time your plenty will supply what they need, so that in turn their plenty will supply what you need. Then there will be equality, as it is written: "He that gathered much did not have too much, and he that gathered little did not have too little." Working and sharing thus both have medical consequences. Working helps prevent illness in the worker, while sharing helps those who are unable to work.

This kind of sharing is not the same as a contractual arrangement in an insurance policy. In fact, insurance is now widely misused by encouraging the "gathering of too much" as if we could purchase perfect medical security while persisting in ungodly behaviors.6 I have known people who existed under the health-threatening strain of a job to which they were ill-suited simply because the health insurance policy was deemed necessary to the family.


Teaching the Biblical Doctrine of Creation as Preventive Medicine

Those who teach the biblical doctrine of creation are promoting health maintenance; it is a corrective for the unhealthy consequences of evolutionary doctrine.? "For although they knew God, they neither glorified him as God nor gave thanks to him, but their thinking became futile and their foolish hearts were da rkened. Although they claimed to be wise, they became foolish and exchanged the glory of the immortal God for images made to look like mortal man and birds and animals and reptiles." (Rom. 1:21-23) I have no patients who worship birds, animals or reptiles, but I have many who think that they are derived from such by evolution, including many Christians who don't see the importance of the issue. For themselves, the Christians may be sufficiently anchored in Christ to avoid the worst pitfalls of evolutionary teaching. By failing to investigate and expose the fallacies of the evolutionary model, however, they support a false system that encourages others to behave like their supposed animal ancestors.

Evolutionary teaching undermines the authority of scripture by means of the interpretive contortions imposed on scripture to make it fit the scientific dogma of the day. Having undone Moses and, hence, Jesus who cited him as speaking God's word authoritatively, similar contortions are invited elsewhere in scripture. It also damages the doctrine that man uniquely bears the image of God. It is intrinsically friendly to abortion, euthanasia and experimentation with human embryos.

With over 20 million U.S. deaths attributable to abortion in the last 15 years, evolutionary teaching can lay claim to being part of the single most damaging health practices in our nation. Does any Christian teacher comprehend the teaching of creationism as preventive medicine? It is. If you are such a teacher, hang out your shingle. You can potentially prolong more lives than an entire generation of physicians who accept the foolish system, or who ignore it as of no consequence. Ideas have consequences, and the idea of evolution has helped spawn severe consequences for our national life expectancy; four thousand unborn people die every day as one consequence of it.

In Figure 2, the years of potential human life lost through abortion in one year are compared with a rough estimate of the potential life lost through deaths during the first year of life from all causes.2 Teachers who try to impart reverence for life to their pupils even if they succeed only 3% of the time, will save as many years of life as the total eradication of all neonatal and pediatric deaths during the first year of life! Sidewalk pro-life counselors who manage to turn aside only 3% of those entering an abortuary could make a similar comparison.

Proper Participation in Communion as Preventive Medicine

How many churches take seriously the preventive health implications of communion? (1 Cor. 11:29-30). Are those at the Lord's table adequately admonished? Has a Christian physician ever seriously considered asking about this matter with a Christian patient who was ill? If not, why not? By whose authority are we limited only to the material causes of disease, that is, germs, hormones, cancers and the like? If we limit ourselves, how are we different from practicing materialists? Why must there be a wall of separation between our religious beliefs and our medical practices? Is it enough that our private and family beliefs are straight?

Some Limits on Preventive Medicine

Probably one of the richest sources of biblical preventive medicine is in the scriptural teachings regarding our position as stewards of what God has granted us. Stewardship sermons can promote health maintenance, at least those which address not only finances but which demonstrate that every aspect of our lives is held in stewardship before God. We appreciate stories of people who were in dire straits, threatened with death on a mountainside or on a life raft, who testify that they came through by sheer determination to serve their mate or their children. They knew themselves to be needed. Why are we impressed only by dire circumstances? What about the mundane? And what about our usefulness not only to our mates or children but for all the people and purposes for which God has placed us here?


Unlike Paul (cf. 2 Cor. 5:6-10), Americans prefer not to be away from the body and at home with the Lord. Instead, we make it our goal to be at home in the body here as long as possible, at whatever cost. We might even take the unduplicated body parts of others, while at an advanced age ourselves, in order to be at home in the body a while longer.

As horrific as it may sound, Paul indicated a godly form of utility. "For I know that this will turn out for my salvation through prayer and the supply of the Spirit of Jesus Christ, according to my earnest expectation and hope that in nothing I shall be ashamed, but that with all boldness, as always, so now also Christ will be magnified in my body, whether by life or by death. For to me, to live is Christ, and to die is gain. But if I live on in the flesh, this will mean fruit from my labor; yet what I shall choose I cannot tell. For I am pressed between the two, having a desire to depart and be with Christ, which is far better. Nevertheless to remain in the flesh is more needful for you. And being confident of this, I know that I shall remain and continue with you all for your progress and joy of faith." (Phil. 1:19-25).

Paul knew he was expendable in God's service.

Pro-life people are rightly afraid of any utilitarian ethic. The intrinsic value of human beings may be replaced by devaluation of the deformed, old, ill, or mentally retarded. The fact that we have utility in God's service does not open to us an ethical means to waste our life or someone else's. We are not privy to God's overall plan. We cannot always know what He is using us to accomplish. An utterly helpless person may be the instrument by which God is teaching others love, gentleness, patience, kindness, sharing or many other virtues. However, if we recall that we are being used by Him, it will help us guard against fencing ourselves with too much preventive effort.

It is inconsistent to sing "Onward Christian Soldiers" while seeking the safety of the rear ranks. We can get hurt up front, but heading for the rear is not the right kind of health maintenance. Whereas God is indeed pro-life, He is most assuredly not pro-life above all other requirements. For example, He does not forbid capital punishment or just wars, though some who have made pro-life their central value oppose these in an effort to be consistent.

The apostle Paul took into account his utility in spreading the gospel. "We always carry around in our body the death of Jesus, so that the life of Jesus may also be revealed in our body. For we who are alive are always being given over to death for Jesus' sake, so that his life may be revealed in our mortal body. So then, death is at work in us, but life is at work in you." (2 Cor. 4:10-12)

Risking death that others might receive the second birth unto eternal life implied risk of illness due, among other things, to malnutrition and exposure. He recounts some of his sufferings in 2 Cor. 6:4 and 1 Cor. 4:10, 11. He utilized his physical body in the calling he had received. He used it up, not accounting his intrinsic value as something to be placed above the use of it in God's service. (1 Cor. 9:27) As he admonished Timothy to endure hardship in his work of evangelism, he clearly portrays this attitude of utility: "For I am already being poured out like a drink offering, and the time has come for my departure. I have fought the good fight, I have finished the race, I have kept the faith." (2 Tim. 4;6,7)

Recognition of our expendability in God's service opens the possibility of sinfully excusing almost any kind of careless treatment of the body with the claim that, "It is in God's service." For example, I could excuse being morbidly obese by saying that it opens for me a ministry to fat people. Not long ago I was visited by an exhausted, depressed minister's wife, accompanied by her husband. Thorough evaluation revealed no physical disease (yet), but a woman sincere in her devotion to God's service, diligently fulfilling her duty to a man equally sincere in his devotion to his pastorate. He admitted that he was devoting insufficient care to her needs, including money and even reasonable housing. He excused it by claiming that his duty to God stood higher than his duty to his wife, making a distinction where none existed. Paul cut the ground from beneath this particular excuse. (1 Cor. 7:32-34) Utilitarian excuses for ungodly risk-taking may be answered by reference to other scriptural principles. Stewardship requires accountability to others in the body of Christ.

We require balance in our priorities, which sometimes must come by the admonition of those under whose authority we live. I recently met a retired stockbroker who devoted most of his waking hours to a program to extend his life. He followed a complex diet and exercise regimen diligently. He had it all on computer and thereby kept exact record of every morsel he ate and each calorie expended. Some evidence exists to suggest that being slightly underfed, minimizing fats and meats, etc., are efficacious to extend life.8 If this is true, does God require such a preoccupation as his? Not at all! Such a consuming pursuit of physical life makes an idol of it.

Though our physical lives are precious and may be too lightly esteemed by our society and by ourselves, we should remember that the even the best physical life we enjoy is distorted; it is abnormal due to original sin. Paul reminds us that "outwardly [physically] we are wasting away, yet inwardly we are being renewed day by day ... So we fix our eyes not on what is seen [our bodies, for example], but on what is unseen. For what is seems temporary, but what is unseen is eternal." (2 Cor. 4:16b,18) Neither medical nor non-medical methods of preventive medicine, therefore, should anticipate being able to do more than slow down the natural deterioration that is our lot since Eden.

Therefore, when an elder teaches on stewardship, the preventive medicine aspects of it could be included. This teaching could include admonitions against lifestyles which lead to premature death as well as against piling up money to guarantee access to every supposed life-prolonging treatment the medical profession may devise. In our nation, in our time, it would be more pertinent to detail some pitfalls in the way people weary themselves to be rich. One family I treat comprises only the husband and wife, at present. He works three jobs and she two. Days pass in which neither sees the other, contact being made by means of notes on the refrigerator door. Such conduct places strain on a marriage and threatens a divorce, which has serious health consequences.4 "Some people, eager for money, have wandered from the faith and pierced themselves with many griefs." (1 Tim. 6:10b). In some families with small children, both parents work in order that the family may enjoy some of the extra "good things of life." If the children are in day care centers, even in good ones, one of the extra things the family may get to enjoy is extra infections in the little ones.9

Preventive Medicine Does Not Always Save Money

A U.S. Senator from Florida wrote one of his constituents to state that if "seniors" would allow themselves to be diagnosed earlier, then "the chance of successful treatment" would be greater and the treatment would be less costly. Even if that were so, which it by and large is not for those near the end of life, it would not save money.'' What would happen is that the elderly person would live to require other services of dependency and to acquire yet another chronic disease which is likely to be more costly to treat, simply because he will be old er and more frail."

In crass economic terms, it is cheaper to die young and expensive to die old. Preventive medical care for the elderly should be defended on the grounds of compassion and what is best for God's kingdom, not societal economics. Socialist arguments grounded in "what the country can afford" are hollow and will echo back awful things in the near future. Pro-life people should avoid them! Economics must be taken into account but by the proper authorities (individual, family and church). We do not hold our bodies in stewardship before the state. The state will not consider the Bible as authoritative in making decisions about health expenditures. Having sold us the economic argument for health maintenance, the state will turn around to plead the same argument when it first permits, then mandates euthanasia.

Other niceties for which we may expect economic justification include growing fetuses to feed upon their tissues when we become sick or older. It may be cheaper, for instance, to transplant a fetal pancreas into a diabetic person than to care for all the awful problems diabetes causes which insulin therapy does not prevent. (Diet and insulin therapy has not been conclusively proven to prevent any of the expensive and crippling sequelae of diabetes.") Abortion will then make money doubly, first for removal for the unborn, secondly to "help" the suffering. Christians and U.S. senators who do not have their ethical sensibilities Biblically honed, will be self-primed to accept euthanasia, abortion and other medical horrors when they are presented as moneysaving, life-preserving procedures.

Conclusion

'Therefore, I urge you, brothers, in view of God's mercy, to offer your bodies as living sacrifices, holy and pleasing to God - this is your spiritual act of worship. Do not conform any longer to the pattern of this world, but be transformed by the renewing of your mind." (Rom. 12:1-2a) A renewed mind transforms us, not a renewed body. The typical Christian's medical approach to health maintenance ignores the renewed mind. Yes, we physicians engage in patient education but not often enough from a biblical basis. Though I have some trouble convincing some patients seat belts are effective (they have a fear of being trapped in a burning or submerging car), the more common problem is in establishing a sufficient motive of responsibility to their Creator and Sustainer. Those who respond do so because of their emotional feelings in such matters. In former days physicians had few efficacious remedies and may have overspecialized in the moral instruction of patients. Today, we have canonized a form of patient education which tiptoes around the health value of moral living, offering false alternatives such as condoms for AIDS.

It is time to alert all that the medical profession does not hold a monopoly on preventive medicine. Far more important are the beliefs of the population, for it is these which give rise to fruitful or disastrous economic systems, to governments, to customs, to healthy or unhealthy practices, to family strength, etc. Biblical teaching in its fulness has more potential influence on physical health than modern narrowly-conceived "medical" ministry. Although the two approaches are actually complementary we have allowed medicine to become a materialistic discipline which has supplanted godliness as a health measure. Personal holiness of Christian practitioners is no substitute for God's rule in medical practice. Relegating health maintenance to the medical profession is not a biblical option of the pastorate.

References

1. Payne, Franklin E., Jr., Biblical/Medical Ethics, Mott Media, 1985, pp. 94, 95.

2. Estimates are taken from data published in Vital Statistics of the United States, 1984, Vol. II, U.S. Dept. of Health and Human Services, Public Health Service, National Center for Health Statistics and from Statistical Abstract of the United States, 1985, 105th edition, U.S. Dept. of Commerce, Bureau of the Census. Mortality estimates are from age-stratified data and based on a life expect ancy of 75 years. No corrections are made for a number of factors, including ex pected spontaneous abortions, IUD-induced abortions, etc. More sophisticated methods of estimation may be found in: Mitra, S., The Effects of Extra Chances to Live in Life Table Functions, Theoretical Population Biology, Vol. 16, 1979, pp. 315-322; Manton, K.G., Patrick, C.H., and Stallard, E., Population Impact of Mortality Reduction: The Effects of Elimination of Major Causes of Death on the Saved Population, International Journal of Epidemiology, Vol. 9, No. 1,1980, pp. 111-120.

3. Ernster, V.L., et al., Cancer Incidence by Marital Status: U.S. Third National Cancer Survey, Journal of the National Cancer Institute, Vol. 63, No. 3, September 1979, pp. 567-585.

4. Berkman, L.F. and Syme, S.L., Social Networks, Host Resistance, and Mortality: A Nine-year Follow-up Study of Alameda County Residents, American Journal of Epidemiology, Vol. 109, No. 2, 1979, pp. 186-204.
-- Schoenbach, V.J., et al., Social Ties and Mortality in Evans County, Georgia, American Journal of Epidemiology, Vol. 123, No. 4, 1986, pp. 577-591.|
-- House, J.S., Robbins, C. & Metzner, HL., The Association of Social Relationship and Activities with Mortality: Prospective Evidence from the Tecumseh Community Health Study, Study Journal of Epidemiology, Vol. 116, No. 1, 1982, pp. 123-140.

5. Newhouse, J.P., and Friedlander, L.J. The Relationship between Medical Resources and Measures of Health: Some Additional Evidence, The Journal of Human Resources, Vol. XV, No. 2, 1980, pp. 200-218.
-- White, Kerr, International Comparisons of Medical Care, Scientific American, Vol. 233, No. 2, August 1975, pp. 1725.

6. Terrell, H.P., Ethical Issues in Medical Insurance, Journal of Biblical Ethics in Medicine, Vol. 1, No; 4, October 1987, pp. 75-82.

7. Payne, op cit., p. 56.

8. Schneider, E.L. and Reed, J.D., Jr., Life Extension, NEJM, Vol. 312, No. 18, May 2, 1985, pp. 1159-1168.

9. Haskins, R. and Kotch, J., Day Care and Illness: Evidence, Costs, and Public Policy, Pediatrics, Vol. 77, No. 6(Z), June 1986, pp. 951-982.

10. Keyfitz, Nathan How Much Would a Cure for Cancer Affect Life Expectancy? Annals of Surgery, Vol. 1, July 1978, pp. Z4-29.
-- Gori, G.B. and Richter, B.J. Macroeconomics of Disease Prevention in the United States, Science
Vol. 200, 9 June 1978, pp. 1124-1130.
-- Johnson, B., 1985, op cit.
-- Gruenberg, E.M. The Failure of Success, Milbank Memorial Fund Quarterly, Vol. 55, Winter 1977, pp. 3-24.

11. Jonsson, Bengt, "The value of prevention: economic aspects." The value of preventive medicine. Pitman, London (Ciba Foundation symposium 110), 1985, pp. 22-37.
-- Cowan, J.A., Prevention - Cheaper or just Better? [letter], JAMA, Vol. 83, August 1987, pp. 383-385.

12. Kozak, George, "Why Treat Diabetes?" Clinical Diabetes Mellitus, W.B. Saunders, Philadelphia, 1982, pp. 43, 50.

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