The Problem With Prevention

Eating right, exercising, avoiding the sun or using sunscreen, moderating alcohol consumption, abstaining from tobacco use, getting mammograms, Pap smears, colonoscopies—almost every measure we’re asked to take to safeguard our future health is difficult. It’s a strange paradox that we have to work in some way, to expend energy, and experience discomfort of some kind in order to gain benefit in life. Wouldn’t it be nice if the most pleasurable things also produced long-term benefit?


But it seems they rarely, if ever, do. Short-term pain appears to be an almost universal requirement for long-term gain. Which, though unfortunate, at least helps explain why people have so much trouble following through on plans to make themselves healthier in the long run. An ounce of prevention may be worth a pound of cure, but even that ounce seems beyond many of us.

The reason for this likely has to do with the kind of reinforcement available to motivate preventive behaviors. Positive reinforcement is generally accepted to be superior to negative reinforcement in changing behavior as it leads to more lasting behavioral modification. In a positive reinforcement schedule, a reward is given after a desired behavior occurs (e.g., a dog gets praise after pooping outside). The most powerful positive reinforcement schedule is called the variable ratio schedule where rewards are given after a random number of responses (meaning a rat will get food after pressing a bar once, then five times, then seven times, then three times, then eight times, etc.). The weakest positive reinforcement schedule is called the fixed interval schedule where rewards are given only at certain time intervals after the desired response (e.g., a rat will get food after pressing a bar only if 10 seconds have passed since the last reward was given).

The problem with reinforcing preventive behaviors is that the reward comes not only too long after the desired behavior (years or even decades) but also in the form of something that fails to happen (e.g., you don’t have a heart attack or get colon cancer or breast cancer). This is called avoidance conditioning (when a behavior prevents an aversive stimulus from starting) and is one of the weakest forms of the already weak negative reinforcement schedule. It explains many failures, including our government’s to invest enough money and resources in anti-terrorist activities until after the Twin Towers fell, despite decades of warnings from experts that a terrorist attack on U.S. soil was an eventual certainty.

Imagine then the psychological factors working against you when you’re confronted with a delicious piece of pie that part of you wants to eat for the reward of immediately feeling good and that part of you doesn’t for the reward of not gaining weight or not having your cholesterol rise and therefore increasing the likelihood of your not having a heart attack in twenty years. If all behavior arises from some motivation, it’s not hard to see why carrying out behaviors that prevent future illness is so difficult.


Certainly, some of us find even the weak reinforcement schedule of avoidance conditioning motivating. Perhaps we’ve already had a heart attack or have a close relative who developed or even died from, say, cervical cancer. But for many of us, the reward of preventing something bad from happening in the future is too remote to motivate desirable behaviors in the present, or to avoid non-desirable behaviors when non-desirable behaviors produce short-term pleasure (e.g., eating fattening foods) or enable us to escape short-term pain (e.g., not exercising). How then can we become better motivated?

  1. Educate yourself. People are far more motivated to act when they not only know why they should but own it themselves. Don’t just trust your doctor. Find out for yourself the benefits of what’s being recommended. Make them your concern, not just your doctor’s concern for you. Learn about them firsthand. Leverage the fact that we’re all more motivated by ideas that feel like our own than ideas that feel like someone else’s.
  2. Tackle one painful change at a time. Don’t quit smoking, start exercising, and radically change your diet all in one week. Pick one intervention at a time and stick with it until it becomes an ingrained habit. Then move on to the next.
  3. Find and focus on the positive benefits preventive behaviors provide you now. The decreased coughing that smoking cessation brings. The extra energy sleeping a full 8 hours a night releases. The peace of mind a negative colonoscopy provides. The benefits each of us finds motivating in this regard will naturally vary from person to person. Think creatively about what can motivate you to take better care of yourself. Find something concrete, something separate from the distant health benefit itself.
  4. Enlist a partner to encourage you and whom you can encourage. Make it a contest between you to see who can make the most long-lasting changes in behaviors that lead to healthier lives. Or make it a competition. Or a series of shared goals. Or whatever works. Attach yourself to a person (or even better yet, to a group of people) who already thinks and behaves the way you want to yourself. Their influence on you will prove to be greater than you expect. Even if this means distancing yourself from some old friends (perhaps who drink too much, or use drugs, or simply downplay the importance of healthy behaviors) and finding new ones—do it.
  5. Remember the glass is always half full. Don’t allow yourself to become discouraged and give up (or fail to start) healthy preventive measures just because you fail at starting or continuing one (e.g., smoking cessation).

Despite the many barriers to adopting preventive care behaviors in our lives, many of us do manage to do it. If you’re struggling to implement new healthy behaviors, a final suggestion would be to talk to people you know who’ve been more successful than you.  Listen to them talk about how they do it, what works for them. You never know what you’re going to hear that will work for you.

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  • I was with you until you brought in terrorism.

    IMHO, we would get a lot more bang for the bucks we spend if we went into the world and did good deeds, instead of “making war on terrorism” and “fighting for freedom.” I think it’s pretty easy for desperately poor countries to hate a rich country like us when we send drones to target villages thought to be abetting terrorists. I’d love to see those dollars spent instead on funding causes such as Doctors without Borders, and looking at ways to make clean water available, etc.

    Instead, Bush’s buddies have been getting rich from the two wars we’re now fighting abroad, as well as the war on terrorism on the domestic front.

    It might be helpful to remember that the USA was the country who armed, and taught Osama Bin Laden how to fight, when the Russians were in Afghanistan.

    Jean: I don’t disagree that the defensive posture we’ve taken against terrorism doesn’t strike at the heart of what causes it. Yet it still remains necessary for us to take steps to protect ourselves. Even if we focused mostly on things like you mention, there would still exist people in the world who would want to do us harm. It wasn’t my intention to use the terrorist example in order to debate the wisdom of our anti-terrorist strategy but rather to point out we only developed one after we experienced a major attack.


  • Alex, I think there are several other things which hold us back from reaching for the long-term benefits, as opposed to short-term pleasure: 1) those of us who lack perspective due to the fact that we haven’t lived long enough–the very young–cannot imagine ANYTHING that is very far into the future; 2) in a similar vein, the younger folks perhaps have never learned about long-term goal-setting from parents or teachers and cannot relate; 3) depressed persons cannot muster the energy to look very far ahead, to something rewarding, or they cannot believe that they will ever be happier; 4) those who do not plan (executive function) simply do not plan ahead (similar to #2). And there are those who simply live for today . . . which at times is a very worthy philosophy.

    Take this example: someone wears his wrist watch into the shower because it is billed as a waterproof watch. The inside of the face gets a little cloudier all the time and the leather watchband starts to curl at the edges and look dried out . . . this person resists the idea that even though the watch is supposed to be waterproof, it would probably last longer and be in better condition if he removed it before showering . . . He continues to wear the watch in the shower . . . I don’t get that line of thinking, but the guy doesn’t seem to mind wear-and-tear . . . (Shrug.)

    Chris: Excellent points, all.


  • Thanks for the list of suggestions. Very helpful. I backed into #3 recently: focusing on the positive benefits that preventive behaviors provide you now. A year ago, I broke my ankle because, from years of de-conditioning due to illness, I couldn’t keep my balance going down the two steps to my bedroom. It was terribly painful and made my illness even harder to manage. At the time, I still didn’t get that lack of balance might have had anything to do with it. Then about three months ago, I saw an article in NY Times on the importance of balance, especially as we grow older (I’m in my 60’s) and the article suggested you test yourself by standing on one leg for the count of ten. Well, I couldn’t get to the number two!

    Still not seeing the connection to the broken ankle, I nevertheless decided that even though I can’t do aerobics, I can practice standing on one leg every other day. That was three months ago and now I can stand on one leg for a count of over 50, even while moving my free leg and my arms around to make it more challenging.

    And I feel different going down those stairs. I feel steady. I feel grounded. I feel safe. I think (although of course I could be wrong) that my lack of balance was why I fell on those steps. It seems that I learned preventative behavior the hard way…but at least I learned!

  • I strongly agree with Jean. You have inadvertently given a very pertinent example.

    Just like a terrorist attack you can never be sure if all the preventive life style really helps.

    I don’t smoke because I don’t enjoy it but I am not convinced that smoking could kill me when Churchill, Obama and George Burns lived longer than many non-smokers.

    Aditya: Taking preventive health measures can’t guarantee a longer, healthier life, but it certainly improves the odds of your having one. I, too, know of examples of heavy smokers who lived into their nineties—but that doesn’t mean smoking doesn’t significantly decrease lifespan, on average, for most people. Knowing that, it only makes good sense to avoid it if we want to maximize the likelihood not only of living longer but of not contracting the many terrible diseases smoking is known to cause. In the example of terrorism, which prevention strategy is the most effective is certainly debatable, but no reasonable person, I think, would argue to have no preventive strategy when we know we’re at risk for future terrorist attacks.


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  • It seems like these days there is so much emphasis on preventing bad things from happening that we have an expectation that, if only we do everything just right, we actually can prevent bad things from ever happening. Read the labels, buy enough insurance, eat less of this and more of that, exercise 3 (or is it 4? or 7?) times a week, etc. A little common sense goes a long way here.

    I also think we are creatures of habit, so when making big lifestyle changes I’ve found it useful to change small habits (one at a time, as you wisely suggest); I read somewhere once that it takes about 30 days of practice to change a habit, and I have found that is true for me. After 30 days, craving for the bad habit is remarkably diminished, and the new one is established. Also, by then, I usually can feel or notice a change of some kind. I lost 25 pounds this way, by changing a few small habits; I’m working on some more. Of course, I sometimes fall back into a bad habit too; for that, I have a saying that I heard somewhere to help me: “Fall down 7 times, get up 8.” Sometimes I think that’s the story of my life 🙂 but sometimes, that’s all you need to do; just get back up again.

    Anne: So true, everything you said. Thanks for the comment.


  • Couldn’t agree more with this:

    “It’s a strange paradox that we have to work in some way, to expend energy, and experience discomfort of some kind in order to gain benefit in life.”

    You live to your promise, that your post could be read in under 5 minutes! Whooa, what a feat!

    I saw your comment on Penelope Trunk’s blog and saw that your name says “Happiness in this World” so I thought I’d peek.

  • I think a lot of people don’t want to go looking for trouble.

    “If I feel fine, I must be fine.” That is their motto.

    Remember the saying “If you don’t take a temperature, you can’t find a fever.”

    Holds true for many.

  • Isn’t your statement, “Short-term pain appears to be an almost universal requirement for long-term benefit” a bit US-centric?

    There are so many other cultures—some which at first glance look not so different from ours—which have not bought into much that Americans do in a day to undermine their health. For example, the French sit down when they eat, and they eat real food, and they usually eat it with family/friends.

    Simple lifestyle choices, being present in the moment, and remembering that habits are choices we’ve failed to make. Taking care of ourselves gives an immediate payoff, if we just pay attention to how we feel and keep our priorities straight.