Chapter 4
Role of Disease
Prevention in Health
Care Reform
[Preventive] Services like these will go a long way in preventing
chronic illnesses that consume over 75 percent of the health care
spending in this country.
Michelle Obama, Washington Hospital,
Washington, DC, July 14, 2010
Prevention gives you a better quality of life . . . but I have never seen
any analysis that shows that in the long-run a society that uses a lot
of prevention will have lower health care costs.
Uwe Reinhardt, Economist, Princeton University
Dr. Bonita Falkner is one of the leading experts in the world on hypertension
and obesity in children and adolescents, and she has participated in crafting the
consensus guidelines that help doctors understand, evaluate, and treat these two
important problems.
Bonnie was born and reared on a farm in Glenwood, Minnesota. After grad-
uating from medical school she came to Philadelphia in the mid-1970s to pursue
58 ◾  Understanding Health Care Reform
her training in pediatrics. She wanted to specialize in pediatric nephrologydis-
eases of the kidney. e only training position available in Philadelphia for pedi-
atric nephrology was lled; therefore, she obtained a position as a nephrology
fellow in an adult training program at Hahnemann Medical College. During
her fellowship she became interested in blood pressure in children.
describes what happened next:
I started taking blood pressures in kids—it wasnt a standard pro-
cedure at the time. We didnt know what was normal and what was
abnormal. Dr. Gotto Aresti, one of my mentors, connected me with
an international group that was interested in blood pressure in chil-
dren. We found that the blood pressure numbers that were used in
adults simply didnt work for childrenchildren would often show
signs of damage in the kidneys and other organs aected by high
blood pressure even at levels of blood pressure that were considered
normal for adults.
ese early observations led in 1977 to Bonnie’s participation in a task force
that created the rst recommendations for how to measure and treat abnormali-
ties in blood pressure in children and adolescents—a task force that she chaired
in 2004. e publication of the pediatric blood pressure guidelines in 1977 did
not have a dramatic eect on the treatment of children because many pediatri-
cians were not comfortable with either measuring blood pressure or using drugs
to treat abnormally high values in children.
In the late 1970s Bonnie began to visit schools, particularly those in under-
served areas of Philadelphia, and city health clinics to measure blood pressure
in children. She would often take medical students. ey would talk to the
children, measure their height and their weight, and take their blood pressure.
A surprisingly high number of the children had high levels of blood pressure
and many were obese. e visits were arranged with teachers and school nurses.
“Today we probably couldn’t do these studies,remarked Bonnie. “We would
need all sorts of approvals from parents and school boards.
Bonnie and her team worked with the school nurses and teachers to edu-
cate the children about the needs to modify their diets. But as Bonnie points
out: “Treating children with therapeutic lifestyle changes is extremely dicult.
It doesn’t work. We don’t have an eective means to change their diets, and
because the children in these underserved areas are economically disadvan-
taged, they can’t simply buy fruits and vegetables and all of the foods that you
want them to eat.Using medications to treat the high blood pressure was an
optionbut “many parents can’t aord medications and until very recently
there were no studies that pinpointed the best medicines to use in children,

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