Yesterday, the Associated Press reported presidential candidate John Edwards as saying that his version of universal health care would make preventive care mandatory. “If you are going to be in the system, you can’t choose not to go to the doctor for 20 years. You have to go in and be checked and make sure that you are OK.” The example he is reported as giving is “that women would be required to have regular mammograms.”

For me, this epitomizes what’s wrong with the flurry of politics around providing universal access to the medical system. On the one hand, it makes prevention an integral part of universal access to medical care.

But on the other hand, it’s the wrong kind of “prevention.” Although Mr. Edwards’s stated aim for prevention includes what I call real, community-based primary prevention such as safe streets, the notion that medical treatments such as screening mammography that fall in the category of secondary prevention should be mandatory is quite troubling.

“Layna Berman, you’re under arrest for failing to get a mammogram. You have the right to remain silent. Yes, I know the evidence shows that survival rates are no better than with self-exams but that’s not our job. We just enforce the law, Mme.” People should want to be and supported in being healthy. If a woman, after careful examination of the evidence, chooses not to have a mammogram or if she avoids it for fear of what will happen to her once she’s in the clutches of medical institutions or if, again after careful deliberation, she finds an effective alternative way to protect herself, why should she be punished? Instead, why don’t medical institutions see this as an opportunity to learn something?

I hear you laughing out there.

The problem runs much deeper than enforcement and the role of personal choice in caring for yourself. One is the assumption that “prevention” means secondary prevention. Primary prevention means doing things that prevent exposures that can damage health, such as eliminating carcinogens from our environment. Secondary prevention means doing something that stops what you might have from getting worse, such as assuming that every woman is at risk of breast cancer until proven otherwise by a medical procedure.

I don’t think I’m mistaken when I say that the common sense meaning of “prevention” is primary prevention: prevent an exposure that can make you sick and not, in Mr. Edwards’s words, “to go in and be checked and make sure that you are OK.” According to whom, we might ask?

There are two other problems. First, responsibility for prevention is misplaced as part of the medical treatment system. Real prevention is people in their communities with the rights, responsibility, and power to not only prevent exposures to health risks but to create a social and physical environment in which they can thrive.

A second, related problem is that by handing over the rights, responsibility, and power to medical institutions, real prevention is held hostage to the culture of expertise. That’s the top-down way health information is communicated and enforced. “You can’t decide whether you’re healthy. You’re not qualified. Put your breast on that plate and shut up or I’ll call the cops.”