One of the pluses of managed care was supposed to have been prevention. But managed care views prevention from a biomedical standpoint rather than one of public health. In fact, we are now witnessing the "biomedicalization of prevention."

We've long known that the most significant contributions to improved health and longevity in the 20th century were community-wide improvements such as sanitation and nutrition. In the last 50 years, however, both the public and private sectors chose to focus on developing health insurance programs for individual care. Prevention fell by the wayside. By 1988, according to the Centers for Disease Control and Prevention (CDC), prevention accounted for only 3% of total health care expenditures. And an Institute of Medicine commission concluded, in The Future of Public Health, that "The responsibility for providing medical care to individuals-precisely because it is so compelling-has drained vital resources and attention away from disease prevention and health promotion efforts that benefit the entire community."

The biomedical model of prevention embraces individually focused, highly technologic approaches that seek to eradicate a disease without addressing the underlying causes of poor health. Consider the following examples:

* A vaccine has been developed for Lyme disease. But people who are vaccinated and fail to avoid tick-infested areas or to wear proper clothing could increase the risk of acquiring other tick-borne diseases such as ehrlichiosis.

* As the use of cholesterol-lowering drugs becomes more common, some users may abandon adherence to low-fat diets-undermining other benefits to be derived from them and possibly compromising health by incurring the side effects of long-term drug use.

* Media campaigns and health education programs designed in the 1980s and early 1990s to promote the adoption of safer sexual practices have lost their appeal to policymakers and have been curtailed. Although advances in antiretroviral medications have resulted in compelling stories of patients who rose from their deathbeds to resume their lives, a December study conducted by the CDC's National Center for HIV, STD, and TB Prevention revealed that rates of sexually transmitted infections among young gay men are rising, most likely because of a return to unsafe sexual behavior-which has dire implications for the fight against the spread of HIV.

This issue of AJN presents some provocative views on prevention. Joelle Machia writes of her involvement in the clinical trial of tamoxifen for the prevention of breast cancer. The study reported that tamoxifen reduced the risk of breast cancer over a five-year period in women at high risk of developing the disease. But in an accompanying commentary, Maryann Napoli challenges the study's conclusions and the very use of the term "prevention."

Napoli is also the author of this month's Viewpoint. She challenges our reliance on routine screening, which can lead to overdiagnosis. She disputes the assertion that mammography, when used for screening rather than diagnosis, improves life expectancy, arguing that it often leads to overtreatment. Her argument is supported by a new report by the Institute of Medicine, Mammography and Beyond: Developing Techniques for the Early Detection of Breast Cancer (available from the National Academy Press by calling [800] 624-6242).

Napoli's Viewpoint is likely to rankle readers. But we should welcome such challenges to our notions of prevention. According to a report in a December 1999 issue of the Journal of the American Medical Association, mammograms every one to two years in women over the age of 40 would prevent 9,632 deaths annually, but smoking cessation would prevent 328,044 deaths each year. While we press for funding for routine mammogram screening, why are we not also pushing for increased spending on smoking-cessation programs? Why are we not lobbying to have a greater proportion of the tobacco company settlement monies used for multimedia campaigns against smoking among teenagers? There are limited resources to devote to prevention. Are we using them wisely?