VOLUME 8: NO. 6, A128 NOVEMBER 2011
Disease and Illness: Prevention, Treatment,
Caring, and Health
Suggested citation for this article: Ursano RJ. Disease
and illness: prevention, treatment, caring, and health.
Prev Chronic Dis 2011;8(6):A128. http://www.cdc.gov/pcd/
issues/2011/nov/11_0255.htm. Accessed [date].
Disease is neither the starting point nor the end point of
illness. It is a pathological process that may not be dis-
covered until decades after the identification of an illness.
Pathologists are the experts in “disease.” Patients have
illness. The disease process may have little obvious con-
nection to the treatment for a patient. For example, strep
throat has never been thought of as a penicillin deficiency,
yet patients can imagine, just as insulin replaces a defi-
ciency, perhaps penicillin may do the same.
What defines a disease? In the article by Tsai et al (1),
nicotine dependence is highlighted as an important and
often overlooked disease of veterans. Certainly, the admin-
istrative records of the US Department of Veterans Affairs
health system underestimate the prevalence of nicotine
dependence, but even so, the risk factors identified by Tsai
et al improve our understanding of possible prevention and
cessation interventions. Mental illness, substance abuse,
and homelessness are major problems for which targeted
interventions may reduce nicotine dependence. We also
know that in the face of disasters — and war is just one
type of disaster — smoking increases, further supporting
that stress and nicotine use are closely tied (2,3). In fact,
post disasters as well as after stressful encounters such
as combat, smoking cessation interventions may be one of
the best ways to identify both those who may benefit from
smoking cessation programs and those with posttraumatic
stress disorder (PTSD).
Nicotine dependence and chronic diseases are “illnesses”
because they require treatment in a particular person.
Treatment targets the disorder, the symptoms, the impair-
ments in physical and psychosocial functioning, disabili-
ties, comorbidities, and the trajectory of the illness. Each
of these is a target for both prevention and treatment.
Only by addressing all of these areas is an illness treated.
Health risk behaviors — such as smoking — are a particu-
larly important target for treatment and medical interven-
tion. Such interventions must address all stages of the
disease and illness and include treatment, prevention,
and caring (4). For example, asking for help is a behavior
necessary for seeking care. Teaching soldiers how to ask
for help and encouraging family members to intervene on
their behalf can bring a disease to medical attention before
it becomes a chronic illness. Similarly, teaching prevention
behaviors such as not smoking or wearing a seatbelt can
prevent diseases such as nicotine dependence/addiction
(aka smoking) and PTSD, which is many times more likely
from injuries sustained in a motor vehicle accident.
The trajectory of illness is a target for treatment and
intervention in itself. Preventing chronicity, anticipating
relapse, and changing interventions in the recovery stage
versus the onset stage are all processes of considering the
trajectory in a treatment and prevention plan. Targeting
the trajectory of a disorder for intervention — for example,
multiple sclerosis, myocardial infarction, depression, or
smoking — means being aware of the difference between
symptoms in the early-onset phase, mid phase, and
chronic phase of the illness. It also means recognizing
the predictors of these phases and adapting treatment to
the phases, including a transient illness, a relapsing ill-
ness, or a chronic illness, all of which may be present in a
single patient over time. The importance of treatment and
prevention strategies in the recovery and rehabilitation
phases of illness and disease is often forgotten in modern
medicine; we send the patient home or fail to arrange fol-
low-up care when the illness appears to be under control.
The phases of the disease each have specific pathology
that is important for intervention and prevention.
Robert J. Ursano, MD
www.cdc.gov/pcd/issues/2011/nov/11_0255.htm • Centers for Disease Control and Prevention 1
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
VOLUME 8: NO. 6
2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2011/nov/11_0255.htm
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position
of the Centers for Disease Control and Prevention.
Let’s consider a broken arm. Perhaps the broken arm is the
second injury. The first was a bruise when the 8-year-old
fell out of the tree, playing while his parents were away. It
was only with the second fall, when he had climbed even
higher, that he broke his arm. If he got to medical care,
the bone may have been set, healed well with recovery
and restoration of function. But if not, perhaps he hid the
injury for several days because of shame and embarrass-
ment, the bone did not set well. An injury has become a
chronic impairment and perhaps a disability. The injury
was preventable 1) by educating parents about attending
to activities of their children even when they are away,
2) early detection of a bruise, 3) educating parents about
shame and embarrassment in children who wish to please,
or 4) educating the young boy how to manage shame and
embarrassment so it does not affect his seeking care.
Example too simple? Apply the same to myocardial infarc-
tion, beginning with mild chest pain that was ignored. Or
smoking, followed by cough, blood in the sputum, and a
Our treatments must span the course of disease and ill-
ness and must precede the onset to gain opportunities for
universal, selective, and targeted interventions for pri-
mary, secondary, and tertiary prevention (5).
So let’s return to veterans and nicotine addiction. Rates of
smoking increase with combat exposure (6). Depression,
PTSD, and other psychiatric disorders are closely linked
to smoking. We now have further information from Tsai
et al that homelessness is also a risk factor. Screening
for PTSD and depression after combat exposure and pro-
grams to facilitate employment and prevent homelessness
are thus well supported for future trials to reduce nicotine
addiction. Such programs are part of treating, preventing,
Robert J Ursano MD, Professor and Chair, Department
of Psychiatry, Director, Center for the Study of Traumatic
Stress, Uniformed Services University, 4301 Jones Bridge
Rd, Bethesda, MD 20814. Telephone: 301-295-3293. E-
1. Tsai J, Edens EL, Rosenheck RA. Nicotine dependence
and its risk factors among users of veterans health
services, 2008-2009. Prev Chronic Dis 2011;8(6):XX.
2. Biggs QM., Fullerton CS, Reeves, JJ, Grieger TA,
Reissman D, Ursano RJ. Acute stress disorder, depres-
sion and tobacco use in disaster workers following
9/11. Am J Orthopsychiatry 2010;80(4):86-92.
3. Nandi A, Galea S, Ahern J, Vlahov D. Probable
cigarette dependence, PTSD and depression after an
urban disaster: results from a population survey of
New York City residents 4 months after September
11, 2011. Psychiatry 2005;68(4):299-310.
4. Institute of Medicine. PTSD compensation and mili-
tary service. Washington (DC): National Academies
5. Mrazek PJ, Haggerty RJ, editors. Reducing risks for
mental disorders: frontiers for preventive intervention
research. Washington ( DC): National Academy Press;
6. Institute of Medicine. Returning home from Iraq
and Afghanistan: preliminary assessment of readjust-
ment needs of veteratns, service members, and their
families. Washington (DC): National Academies Press;