Prevent or perish - the choice is ours

PUBLIC HEALTH OPINION   111111m1111

BY PROFESSOR STEPHEN LEEDER, EMERITUS  PROFESSOR

PUBLIC HEALTH, UNIVERSITY OF SYDNEY

HPV vaccine has transformed the prevention of cervical cancer.

We eliminated smallpox and perhaps we will yet dispatch polio. The dreadful infectious diseases of childhood are  much

diminished, at least in affluent societies. These good news items about prevention are welcome.

Prevention must be safe

But prevention can readily get a bad name. The controversy over statins - resolved in their favour only recently in a massive review of randomised trials published in the Lancet - illustrates how easily preventive strategies can be blown off  course.

The late, great epidemiologist Geoffrey Rose pointed out that while taking a risk on a treatment and suffering side effects may be tolerable when you are ill, this is not so with prevention. Here, we are dealing with well people and if we place even one in 1000 in jeopardy by our preventive intervention, the red flag will be waved, publicity will follow and the intervention will likely be abandoned.

The anonymity of prevention

Prevention suffers further - from anonymity. A preventive intervention in the community, such as separating the drinking water supply from pollution or removing a 'black spot' intersection from a highway, will save lives. But who are the people whose lives have been saved? We will never know. The ·grateful patient' is

not a person whose disease has been prevented, but rather one whose life has been saved through effective treatment.

,The matter of anonymity goes.further. Consider taking a drug that lowers blood pressure. Not everyone with elevated blood pressure who does not take the medicine will suffer   a

consequence. Not everyone whose blood pressure is lowered because of treatment will get a benefit. This muddle - some treated develop problems, many untreated don't  -  diminishes the credibility of prevention. We all know smokers who lived robust lives until they were 90 and we all know people who died before age 55 who were svelte, vegetarian, non-smokers who never sat down.

It is important to understand these attributes  of prevention if  we are to work out how to give it support. Simply put, there are few votes in prevention. Think suicide. Because prevention is anonymous and unpredictable and incomplete, it is unlike new surgical units, rescue helicopters and knee replacements. It is politically  intangible.

But what to do about today's epidemics of chronic disease?

And yet. The perfectly reasonable question about our current and future disease profile is this. Given its magnitude and its clear association with where and how we live our lives, and the evidence that its incidence can change with changed environment, will we choose to offer health care endlessly to an ever-growingnumber of people who have succumbed to these chronic problems, or will we move our investment in health care, and lend our political weight, to programs that seek to prevent these problems?

I recently printed three documents about obesity. They weighed 1.8 kilograms. Two were prepared by consultancies

- McKinsey and PwC - and the other came from the World Health Organisation. McKinsey, after a thoroughgoing analysis of the prevention literature , argued pragmatically that we should develop obesity preventive strategies that contain every intervention from childhood to dotage that has even a  trace

of evidence that it works. Put prenatal and early childhood interventions with adult cooking classes and food labelling and city planning and cycleways and readily available fresh food.

Social determinants

Sir Michael Marmot, an epidemiologist from London, has given this year's Boyer Lectures on the ABC. In them he urges us to look for the 'causes behind the causes'. A Sydney University graduate, he is now president of the World Medical Association and was previously , among many other things, President of the British Medical Association as well. He argues that the enemies of good healthcare are injustice and poverty, and to do nothing about them is a dereliction of medical duty.

The AMA strikes back

Before the last election the AMA called for a national strategy for prevention, a systematic approach to supporting efforts to reduce our dependence on the towing truck service of medicine in dealing with chronic and complex diseases and to favour prevention.

We need it - urgently.

As doctors we would do well to remember our roots. Long before we had effective remedies we were all public health physicians and much kudos helped develop the status of medicine because of our preventive agility and ability.

Lots to do here, and we need the help of the community and politicians in tackling 'the causes of the  causes·.

  Published in Australian Medicine 17 October 2016 http://bit.ly/2eDwGik