Future positive

The argument in this book rests on a simple proposition: understanding the reason why people prefer to take a chance on sickness and cure is the key to persuading them when and why they should choose prevention instead. This final chapter summarizes the means of persuasion: investigate rather than presuppose which criteria are used to make health choices; build systems for accounting (inclusive costs and benefits of prevention) and for accountability (liability and responsibility); offer ways to improve health, not merely ways to avoid losing it; evaluate, in order to manage, the perceptions linked to health hazards; exploit the logic of choice to insure against the risk of unlikely disasters, to increase the present value of future threats, to foster cooperation as a basis for prevention, to map out the practical pathways to prevention, and to remedy the under-investment in prevention research. The tools of prevention are the means to a greater end—health as a ‘state of complete physical, mental, and social well-being’.

The culture of conveniences

Despite thousands of years of toilet culture and technology, and despite the obvious benefits of sanitation for health and well-being, the great majority of people alive today do not have access to a safe system for removing human waste. The installation of safe sanitary systems depends on cooperation among many kinds of providers and users. Their collective goal is to align the benefits for health with personal and social preferences for toilet use and hygiene, while exploiting other benefits from agriculture, energy, education, environmental protection, housing, and flood protection. For individuals, families, and communities, toilets are not merely, or even mainly, to protect health. Rather, their acceptability hinges on convenience, privacy, personal safety, and dignity, where preferences are rooted in societal norms. Providing safe sanitation for all is not merely a health intervention: it is one of the mutually reinforcing processes of cultural, social, and economic development.

Our children’s children

Climate change is prevention’s biggest challenge—its effects on health and well-being will be wide-ranging, long-term, and global. The pressures and opportunities for action are growing as the risks and hazards become clearer, greater, and nearer. Mitigation—cutting greenhouse gas (GHG) emissions (primary prevention)—benefits health, economy, environment, and society through agriculture, transport, air quality, energy supply, and waste management. Adaptation (secondary prevention) is the essential back-up when mitigation fails; there are strong incentives for local adaptation to counter predictable local threats such as extreme urban temperatures, flooding, and water scarcity. Carbon taxes are a powerful but underexploited mechanism for reducing greenhouse gas emissions, so need to be reinforced by other incentives, including subsidies for wind, solar, hydrogen, and hydropower. Now more than ever, the pressure for transformative action on climate change has the potential to stimulate sudden and rapid movement towards clean energy sources and technologies.

History of a hypothesis

The main ideas about preventing illness run through the whole of human history even if, in every age and in every place, they find new interpretation. Spanning 5,000 years, this chapter reveals prevention’s common themes, including the following: illnesses have preventable causes (Neolithic filtration and boiling of water); the choice of prevention over cure is conditional on the balance of costs and benefits, where the benefits depend on the risk, timing and severity of the hazard (shipping insurance, from 4000 BC); prevention is about improving health, not merely avoiding illness (Ancient Greece); prevention is for communal as well as personal health (Roman aqueducts and communal toilets); prevention is at a premium in the absence of a cure (fourteenth-century plague); the costs and benefits of prevention can be calculated and used to make choices about health (Franklin on fire insurance, Chadwick on sanitation); and the immediate, preventable causes of illness (diet, tobacco) depend, in turn, on deeper causes, in societies, economies and environments (Hippocrates to the Sustainable Development Goals).

The problem of prevention

Most people aspire to healthy living but staying healthy and preventing illness carry a cost—counted in money, time, effort, information, trust, and willpower. The principles of prevention can be framed as a conditional, testable hypothesis: prevention is more likely to be favoured when individuals or populations can choose, given the constraints presented in any setting, a low-cost, high-efficacy method of averting a large, probable, imminent threat to health. The decisions that people make about health depend, not only on quantified options, risks, hazards, and timing, but also on the incentives, motives, powers, and values of everyone who has a stake in the outcome—individuals, governments, non-governmental organizations, businesses, and others. Data presented in this chapter suggest that more money and effort are invested in prevention today than is commonly thought, but the enormous, persistent, avoidable burden of ill health is a reason to seek ways of investing still more.

Normal ways to die

Familiar endemic diseases such as tuberculosis (TB) are rarely seen as health emergencies, even though they kill millions of people each year. This chapter describes a variety of ways to remedy the neglect, illustrated by TB, including: highlight new dangers from old hazards, such as the emergence of multi-drug resistant strains; eliminate the prevention–cure dichotomy by exploiting the benefits of ‘treatment as prevention’, when drugs that cure illness also prevent the transmission of infection to others; neutralize major risks for TB, such as co-infection with human immunodeficiency virus (HIV), in settings where these risks cause a high proportion of cases and deaths; and mitigate the large number of weaker TB risks that have benefits for other health conditions (diabetes, undernutrition) and for society more widely (homelessness, crowding). This wider context aligns the specific aims of neglected disease control with the larger goals of Universal Health Coverage and the Agenda for Sustainable Development.

The burden of choice

Consumers are ultimately responsible for ‘behavioural’ risks to their health, but the behaviours in question are also those of manufacturers and governments, and the burden of choice on consumers is lighter when shared. Governments, in particular, have the motives, means, and powers to intervene between commercial supply and consumer demand. Among the most effective instruments of government are taxation and regulation, especially for the control of single, major causes of illness such as tobacco and sugar. Taxes put a value on the future, today: consumers and manufacturers can choose to pay immediately for the costs incurred to society in future, or switch to healthier lifestyles and business practices. In practice, governments under pressure from lobbyists tend to under-tax harmful commodities, so other enticements are needed too. In this context, empirical studies show health promotion is complementary to disease prevention—making health gains while avoiding health losses—especially when the joint benefits for health are large.

The affordable dream

Prevention is integral to achieving health equity and Universal Health Coverage. And yet prevention is a healthcare orphan: it is not usually a priority in the health sector or in any other sector of government. This chapter suggests five ways to redress that disadvantage: give prevention and public health budgets that are separate and protected from medical services, based on demonstrated benefits; define the goals of prevention in collaboration with, and considering the objectives and values held by, those who make the decisions; reassess the value for money provided by preventive methods that presently command large budgets, such as ‘healthy condition monitoring’; stimulate latent public demand for prevention by improving access to screening programmes, calibrating health insurance to favour prevention, and through workplace health promotion schemes, among others; and improve the appeal of prevention across the whole of government (beyond the health sector), using evidence to reinforce the long-standing goal of putting ‘Health in All Policies’.

Unlikely disasters

If the threat of disaster—an earthquake, a pandemic, or a nuclear accident—is unlikely or uncertain in time, place, and scale, then prevention may not be seen as better than cure. A potential health emergency becomes more manageable when the cost is commensurate with the hazard and the risk. Tactics to satisfy that criterion are familiar to the insurance industry: spotlight preventable hazards, pool the risks, and share the costs. A hazard—such as COVID-19, Ebola or Zika virus—is perceived to be more dangerous, and more likely to stimulate action, when classified as a public health emergency or a threat to national security. Among the methods for pooling risks and sharing costs are early detection and response systems for multiple pathogens; platform technologies for the development of new diagnostics and vaccines; collaborations through the International Health Regulations (IHR 2005); and shared genomic databases for bacteria and viruses.

Epilogue

Once a year, Geneva’s cycling enthusiasts get together for the Cyclotour du Léman, a 180-km bike race around the lake. In 2020, COVID-19 intervened, forcing postponement from warm May to cool October. Then, at the last minute, they restricted the route out of Geneva to a 55-km leg to Lausanne....