Top sales pitch needed for investment in prevention
I was once asked by Malcolm Turnbull, serving on a Parliamentary committee inquiring into health care, what I would do if today I had awoken to discover that I was the Minister for Health.
I replied that I would immediately have closed the blinds, taken to my bed and tried to go back to sleep on the assumption that this was just a ghastly nightmare.
Consider your dilemma, if you were Minister, between investments in prevention versus investments in hospitals. The demand for more and better hospitals is relentless. To under-invest in emergency departments, for whatever reason – including prevention – is to court electoral backlash.
One problem with investing in prevention is that nothing very visible happens, at least immediately, if it works.
If you are a prevention professional or politician supporting prevention there will be no crates of Champagne on your doorstep on Christmas morning from grateful people who have not had an accident or not become ill because of your preventive efforts. They, and you, will likely never meet: the preventive transaction is anonymous. It is surprising that we invest in prevention at all, and even more surprising when you see that we do so at a level higher than many people think.
Consider successful prevention programs, and the social and political contexts in which they occurred. Take as examples tobacco smoking, seat belts and immunisation. Three common features stand out in relation to these examples as having contributed to their success.
First, the community needs to be worried. They may be worried about a disease, but less convinced about how to prevent it. Think about lung cancer. As R.N. Proctor from the History Department at Stanford University put it last year,
“Lung cancer was once a very rare disease, so rare that doctors took special notice when confronted with a case, thinking it a once-in-a-lifetime oddity. Mechanisation and mass marketing towards the end of the 19th century popularised the cigarette habit, causing a global lung cancer epidemic. Cigarettes were recognised as the cause of the epidemic in the 1940s and 1950s, with the confluence of studies from epidemiology, animal experiments, cellular pathology and chemical analytics. Cigarette manufacturers disputed this evidence, propagandising the public … As late as 1960 only one-third of all US doctors believed that the case against cigarettes had been established.”
But now, concerned and informed communities and professionals in economically advanced nations are convinced, and effective tobacco control has won political support and legal action. Cigarette smoking rates have fallen to less than 20 per cent in parts of the US and Australia.
Second, for preventive programs to win support, it helps if they can be shown to work. In 1968, I worked in the western highlands of Papua New Guinea. My predecessors had introduced immunisation, so that when a whooping cough epidemic ignited, the children in our valley were spared. Neighbours were deeply impressed and wanted to know our magic.
Similarly, with seat belt and breathalyser legislation, results followed rapidly, securing these preventive programs in the minds of the public and politicians alike.
Third, because preventive programs are for the well population, we need to ensure that they are scrupulously safe. As the late Geoffrey Rose, an eminent London epidemiologist, used to say, side-effects are tolerable when you are treating a person with a severe illness – witness chemotherapy – but never when you are seeking to prevent illness in a well community.
Concerns are expressed about the exposure to ionising radiation during mammographic screening. This risk may be very low (a lifetime additional risk of cancer of between I in 10,000 to 1 in 100,000 per year), but when applied to large populations, the risks add up. Indeed, many forms of screening, especially if disconnected from general practice, have been shown to carry serious risks: screening is an ambiguous preventive enterprise – seductive, but often a health hazard. If the preventive step is not incredibly safe – think pink batts – the program will not be sustainable. Best to be rid of the glitches before scaling up and applying to the population.
So, if we are keen on prevention, we should be alert to the community context and the political interpretation of what we are proposing.
We will need all the insights we can find to help us with the big preventive challenges that have to do with the way we live, the food we eat, the cities we design and the transport systems we devise.
This is not the time for the faint-hearted! No rushing back to bed, thanks minister!