Last February, the New England Journal of Medicine ran a potentially misleading review of the cost-effectiveness of illness prevention strategies that may have led many casual readers (such as the editors of the Washington Post Health section) to conclude that most health-improving measures -- such as aggressive counseling for people who are either overweight or smoke -- cost more in the long run than they are worth. This morning, the Journal of the American Medical Association carried a proper antidote by Steven H. Woolf of Virginia Commonwealth University, who is fast becoming a leading expert on prevention techniques for improving the nation's health.

Woolf admits that personal behavior is difficult to change, and many intervention strategies for preventing disease cost more money for the health care system than they save. But he takes direct aim at the NEJM article claim that "drew similarities between the cost-effectiveness ratios of prevention and disease treatments, all but ignoring the much lower cost-effectiveness ratios of the preventive services that guidelines advocate."

But touting those physician-delivered prevention services that are cost-effective is not the core of his argument. The health care system is the improper vehicle for delivering the most cost-effective preventive services and strategies, he argues. "Behavior change occurs where people live -- at home, work and school -- but the community offers little infrastructure for modifying lifestyle."

Advertising, school lunches, restaurant menus, entertainment media, convenience technologies, and the built environment discourage physical activity and promote consumption of calorie-dense foods, large portions, tobacco, and alcohol. Social conditions (eg, inadequate education, impoverished communities) impose additional barriers.

Boosting prevention is only partially a question of how our society allocates its health care system resources. A properly defined prevention campaign requires tackling issues that lay beyond the health care system. Imagine calorie counts on every fast-food and chain restaurant menu. Imagine rejuvenated big city public health departments sending skilled nutritionists bearing dietary advice and training into low-income neighborhoods suffering from some of the nation's highest obesity rates.

Giving people the tools to help themselves lose weight is the first step in the process of reversing the nation's obesity epidemic. (A new study, also published in today's JAMA, showed the rate of childhood obesity has finally stopped growing, but about a third of all kids are still either obese or overweight, about triple what it was in the 1960s and 70s.)

Woolf's hope is that the demonstrable effect that deteriorating health is having on longevity and the economy will generate the political will to act. "Self-interest (living longer and healthier) and common interest (economic stability) may inspire the personal sacrifice of getting healthy and the collective sacrifice (by the private sector and the state) of mobilizing the resources to make it happen," he concludes.