I have spent the greater part of my adult life asking a simple question: Why are hospitals the way they are?

The longer I worked in healthcare, the more convinced I became that we have built a system that excels at responding to catastrophe while underinvesting in preventing it. Every patient deserves the best treatment possible. But why are we so much better at paying for the help at the bottom of the cliff than putting in the guardrails at the top?

That question came back to me while reading excerpts from Malcolm Gladwell’s conversation with Dax Shepard and Monica Padman about his new book, The American Way of Killing: The Invention of an Epidemic.

Gladwell compared Los Angeles and Berlin, two cities with nearly 4 million residents each. He said the LAPD has about 8,000 officers and Berlin has18,000. More than twice as many officers serving a similar population.

According to Gladwell, Western European cities have about twice as many police officers per resident as American cities. His point is that we emphasize incarceration after the crime, while Europeans invest more in policing before it. We pay for the consequences via more prisons. They emphasize prevention.

The difference in lethal violence is mind numbing. In 2023, the American homicide rate was approximately six per 100,000 people. Across the European Union, it was one. That is six times the risk of being killed here. Read that again.

Those numbers don’t prove that police force size alone explains the difference. Guns, poverty, social conditions, and other factors matter. But they do suggest we should look at what other countries are doing before saying our approach is the only smart one.

Gladwell makes another distinction: theft and homicide are not interchangeable problems. Some European cities have more property crime than American cities. America’s outstanding problem is lethal violence. A stolen car and a murdered child are not the same.

As I listened to his observations, I realized I was hearing a healthcare argument in a completely different setting.

In medicine, we know many major risk factors: poor nutrition, obesity, smoking, alcohol abuse, sedentary lifestyles, chronic stress, and social isolation. Yet we spend billions treating their outcomes while not supporting wellness and prevention.

Think about these reverse incentives.

If a community becomes healthier, hospitals perform fewer procedures and making payroll twice a month becomes more challenging. Pharmaceutical companies will sell fewer medications. Fewer people would need complex interventions. From a societal standpoint, that is an incredible success. But our payment systems reward volume, and prevention reduces revenue.

The same question applies to violence. Gladwell describes trauma surgeon Edward Cornwell, who estimated he had treated approximately 3,000 gunshot wounds, the Michael Jordan of gunshot surgery. That represents unbelievable medical expertise, but it also represents thousands of cases where prevention failed.

He describes a Southside Chicago emergency physician who had lost fifteen close friends, including his brother, and relatives to violence. Imagine taking those losses into work while trying to save the next shooting victim.

We have built incredible systems for managing the wreck after it happens, but we have invested much less in preventing the wreck.

Community policing, violence interruption, mental health services, mentoring, and neighborhood improvements deserve serious consideration and support. They are the equivalent to wellness initiatives and preventive medicine. They can stop the injury before it occurs. The Whole Health movement.

I am not suggesting some grand conspiracy. The vast majority of people working in healthcare, law enforcement, and government all want better outcomes. What I am suggesting is that our economic system rewards treating expensive problems much better than making them disappear.

Those preventive investments don’t produce quarterly earnings reports. They produce something far more valuable. They produce fewer funerals.

Gladwell asks us to rethink violence through prevention. Healthcare taught me the same lesson decades ago.

The most important question is not how efficiently we respond after tragedy. It is whether we had the financial courage to prevent it in the first place.