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
