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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
Tuesday, September 27, 2016
The healing power of words
Rebuilding your personal identity after a
serious relationship breakup can be like assembling a piece of IKEA furniture,
argues Ethan Kuperberg in a humorous one-page article in the September 12 issue
of The New Yorker titled 'How to put your Sëlf together.'
Leaving your Sëlf
unattended during re-assembly "can result in injury, error, or [worst of
all] poetry." So should doctors
have anything to do with this traumatic consequence called poetry?
To our ears poetry is foreign although in other
times and places it was familiar. It is not the language of business, politics
or science. Instead it links to art,
drama, sculpture, and music, especially to song. It enables feelings of love and loss, of
ecstasy and sadness not easily otherwise expressed to find a voice. The
contrast of prose and poetry is incomplete and prose can of course be brilliant
as a vehicle to carry these feelings.
Also, overlap occurs between prose and poetry, and 'prose poetry'
follows. But poetry has unusual strength for this communication.
Because there are many forms of poetry - long
and short, rhyming (simple or complicated), tightly disciplined or free,
inscrutable or accessible, concrete or abstract - there are many definitions, none
entirely satisfactory. Despite the variety in poetry and its definitions,
several common features can make it attractive to doctors.
First, poetry can express our deep feelings when
patients or family or friends suffer and die. It enables these feelings to be
explored, articulated and shared without the heavy transactional processes of
prose. Doctors whose encounters with death and suffering are common and
profound use poetry to express their feelings. Patients and carers do likewise.
Second, poetry can enable the expression of
achievement - liberation, cure, safe birth, the lifting of depression - that
are not enumerated in key performance indicators that tend to reflect processes
and financial efficiency expectations of the clinician. It can share an
elemental connection to love and happiness that bypasses the bureaucracy of
measurement and computation.
Third, poetry reveals deep things about the shy
poet and his or her subject that he or she would find difficult otherwise to
share, uncovering the soul in its naked austerity. Not all doctors are extroverts, not all
express their feelings openly. They may be more comfortable speaking from
behind the veil of poetry.
It is a mistake to think that poetry is simply
random jottings that require little effort. In fact, it is an art form that
carries its own discipline like learning a musical instrument. I have
benefitted from membership in a poetry writing group that meets each week with
an expert tutor to share poetry and critique one another's efforts. I have come to enjoy the way poetry makes me
consider and savour each word, and the fellowship of poets from different
backgrounds. It is rich in metaphor, analogy and simile and light on
description, depending more on evocation, suggestion and impression.
The great Irish poet Seamus Heaney had a
brilliant talent for turning words, like diamonds, through ten or more degrees
allowing the light to diffract into new colours, astonishing the reader with
their novelty. Take for example the first stanza, especially its brilliant last
line of his poem 'The Sharping Stone':
In an apothecary's
chest of drawers,
Sweet cedar that we'd
purchased second hand,
In one of its weighty
deep-sliding recesses
I found the sharping
stone that was to be
Our gift to him.
Still in its wrapping paper
Like a baton of black
light I'd failed to pass.
Poetry allows me to search my mind for
interpretations of events and people that are not immediately obvious. Others might access these insights through
meditation, but for me, sitting at the laptop with no more than the germ of an
idea of the poem and then watching it emerge, expands my understanding of those
events and people.
The Scandinavian Nobel laureate poet Tomas
Tranströmer suffered a devastating stroke in 1990, leaving him hemiplegic
and without speech. His recovery was
gradual and never complete, but he returned to playing the piano with his left
hand. He returned to writing short poems.
I wondered about his experience - lived as it were from the inside. So I wrote a poem, beginning with the
confusion and disorientation of the acute phase of his CVA, as he might have
experienced it. I tried to use his voice, his style, for this purpose. One
snippet of this quite long poem, The Stroke of One, reads:
In a flash my spirit
was caught like a
fish in a net,
my flesh pulled and
spun
through an unfamiliar
deep.
I do not claim that this poetic exploration was
helpful to anyone, least of all Tranströmer, but I feel
differently about the stroke experience as a result. Maybe that makes me a better person to
understand strokes in others or in myself if I were to suffer this fate. You can find the complete poem on my poetry
blog Stephenleeder.blogspot.com.au along with others from recent years.
Although I do not have the epidemiological
evidence, it is said that poets are miserable people who often end their lives
by suicide. The search for meaning and interpretation that underlies much
poetry can be a manifestation of human alienation or depression. But as a counterweight, read Shakespeare's
sonnets or the Psalms of Degrees.
As with art, drama and music, there is room for
the expression of great happiness in poetry. The process of poetic reflection
mines happiness from our unconscious like precious ore - it is free and for our
pleasure!
Published in Australian Doctor 28 September 2016 http://bit.ly/2cBvJqm
Tuesday, September 6, 2016
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