Rose’s Strategy of Preventive Medicine

"I’m sorry that I didn’t know about this book until pretty far on in my career – but it’s a fantastic book that explains why and how disease occurs in society. We think of the need to treat people who are very ill, and of course we need to do that. What Rose talks about is that for most human illnesses there’s a bell curve distribution. If we just treat people for disease that will do some good, but we can do much more good by shifting the distribution of that bell curve. That’s the essence of prevention, that’s the essence of maximising health by reducing the number of heart attacks and strokes. It’s not either/or – we can do both. So, for example, to reduce the number of heart attacks and strokes we can treat people who have high blood pressure and that’s very effective, but we can also get people to exercise more, be at healthier weights, eat lower sodium food and that will shift the bell curve so that many fewer people need treatment and the people who need treatment won’t need it as badly. I don’t think it’s an either/or for population health and individual health. But I do know population health tends to get the short shrift. Until around the middle of the 20th century virtually all improvements in health were the result of prevention, not clinical care. Clinical care might occasionally have saved someone through surgical or other interventions but it wasn’t effective enough or widely accessible enough to actually make a meaningful difference with how many people lived or died overall. “Until around the middle of the 20th century virtually all improvements in health were the result of prevention, not clinical care” That started getting better with antibiotics and with the treatment of cardiovascular disease. In the US between 1980 and 2000, the death rate from heart disease was cut in half. Half of that decrease was from community prevention, particularly tobacco control, and half was from clinical care, such as taking care of people while they were having heart attacks. That tells me that both community and clinical care can make a huge difference. Interestingly, there was a similar study in the UK that showed that 80% of the life years saved were saved through community prevention. Community prevention measures saves lives at a younger age. That’s really what Rose emphasises – the tremendous power of even small changes in the population prevalence to make huge changes in health. I have my underlined copy of Rose in front of me, open to a certain page, which I’ve often thought of because Sir John Crofton mentioned something similar. I underscored a passage where Rose wrote, “Of all the threats to human health, it is alcohol which causes the widest range of injury. It shortens life, being variously held responsible for between 1% and 10% of all adult deaths in industrialised countries. It shrinks the brain and impairs the intellect. It causes failure of the liver, heart and peripheral nerves. It contributes to depression , violence and the breakup of personal and social life. It has been blamed for a quarter of all deaths on the road – divided about equally among drunk drivers, drunk pedestrians and innocent victims.” Alcohol is a really tough area. Sir John always encouraged me to do more on alcohol control. The issue is problem drinking. In the US, binge drinking causes a huge proportion of the harms. Yet problem drinking is a challenge to address. I think we can at least begin to address this problem with a focus on kids and understanding that you want people to make decisions that are going to affect the rest of their lives when they’re adults, not when they’re kids. There’s been various work done in economics that suggest that although we spend a lot on healthcare, we get a lot for it. We want to have our hip or knees fixed so we can walk again. We want to be kept healthy. This is a delicate area but I will say that I wish we could just have a more open discussion about end-of-life issues. As a physician I’ve taken care of patients who died horrible deaths that they wouldn’t have wanted because they had not had a conversation with their families about what they wanted, and for whatever reason their families felt that we should continue to prolong the life of someone who is not really living but dying. And I will say that for my father and my grandmother, both of whom I was very close to, the last two years of their lives were very unpleasant. This was really something they would never have wanted and yet we are not able as a society to have clear discussions and decisions about that so that people can choose how they want to live and how they want to die. I would highlight one: The need for strong public health institutions in poorer countries. Improving health entails getting data to drive decisions – data on what’s making people sick, data on whether the programmes that are designed to help are actually working, data on whether the healthcare system is doing what it needs to do, data on what works in different communities to protect people from threats, and data on what threats are spreading. To get all that data you need strong public health institutions. I think CDC does a great job in the US. When I travel in Africa, Asia and Latin America I virtually always get asked: How can we create a CDC for our country? That is the next big global challenge for public health. There are economic interests that can make it challenging. The tobacco industry is a primary example. Tuberculosis bacteria don’t lobby politicians. It doesn’t rebrand itself as light TB or get a movie star to make TB look sexy. So one is the economic interests. Second is the need to get clear about responsibility. There are people who say if the government does this it will sap individual responsibility, or, it’s because you’re not treating people as autonomous adults. It’s not either/or. Take driving as an example. The government has a responsibility to make sure that traffic lights work, that the speed laws are enforced, that people don’t drive drunk. But that doesn’t absolve individuals from their responsibility to drive safely, to not drink and drive – it’s a shared responsibility. We need that for tobacco, for alcohol, for heart disease and cancer. We can now vaccinate against cancer from hepatitis B so maybe one day we’ll be able to use vaccines for heart disease, stroke and smoking. But not yet and we shouldn’t wait because we do have effective things that we can do today that will save millions of lives. Saving lives requires good information, good management and focused action. These books really highlight that. They show how understanding what’s causing disease, finding the tools to stop it and working together as a society can save millions of lives."