Jul 29, 2009

Actually, preventative healthcare has been a spectacular success

Simon Chapman responds to Bernard Keane's contention yesterday that prevention is not always the best cure when it comes to health reform.

Bernard Keane got a bit excited yesterday, thinking he was onto a major myth-bust: that prevention may not be better than cure. Citing a New England Journal of Medicine review of prevention’s ability to cost save, he faithfully reported the finding that "Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not." Now who ever thought that by simply uttering the magic word "prevention" that any intervention would either work (prevent disease or save lives) or save money? Just like treatments, prevention has its fair share of useless fads and non-evidence based enthusiasms. But prevention’s track record in Australia is spectacular. Consider these:
  • Lung cancer, easily the leading cause of cancer death, was a rare disease at the beginning of the 20th century. With the advent of cheap cigarettes through mechanisation of production, lung cancer rose until about 1982 in Australia. To find today’s rates of male lung cancer, you have to time travel back to 1963.
  • To find rates per 100,000 of chronic obstructive pulmonary disease -- a disease which cannot be cured but which is the fourth largest killer of Australians today -- you have to go back to the late 1950s. Again, thanks almost entirely to tobacco control. Michael Thun, the American Cancer Society’s top epidemiologist, commenting on the first historic downturn in overall cancer deaths in the USA:"Even our most conservative estimate indicates that reductions in lung cancer, resulting from reductions in tobacco smoking over the last half century, account for about 40% of the decrease in overall male cancer death rates and have prevented at least 146 000 lung cancer deaths in men during the period 1991 to 2003."A more realistic straight line projection of what lung cancer rates might have become suggests that, without reductions in smoking, there would have been virtually no reduction in overall cancer mortality in either men or women since the early 1990s. The payoff from past investments in tobacco control has only just begun."
  • Male rates of heart disease deaths are now as low as they were in 1945, and female as low as they were in 1947. Some of this success is due to treatment, but much of it is due to primary and secondary prevention.
  • Cervical cancer deaths in Australia are at all time lows thanks to the long term promotion via education campaigns and through doctors of Pap smears.
  • Thanks to the boost provided by former health minister Michael Wooldridge, hospitalisations from vaccine preventable diseases fell 21.9% from 7238 in 1996-2000 to 5651 in 2000-2002. Deaths fell 55% in the same period.
  • Despite population growth, Australia’s road toll is 44% lower today (1616) than it was in 1986 (2059).
  • Australia’s suicide rate has fallen to its lowest on record. There were more than 2,700 deaths in 1997, falling by a third to 1,800 in 2006.
  • Australia’s 1996 gun laws followed 13 mass shootings in the 18 years before. In the 13 years since, there has not been one such massacre because of the odious "regulation" so despaired of by Keane
  • The heterosexual HIV epidemic that the Grim Reaper ads threatened us with in the 1980s, failed to materialise thanks to community health promotion campaigns and harm reduction policies.
  • Thanks to SIDS epidemiology and the health education campaigns based on it, the SIDS death rate per 100,000 live birth declined 52% from 189/100,000 in 1982-86 to 81/100,000 between 1992-96.
In 2001 Philip Morris warned the Czech government of the folly of tobacco control, pointing out that smokers had the decency to die early often around retirement age, thoughtfully avoiding the state pension and other cost of human aging. Philip Morris argued that the Czech government saved $30 million in 1999 by not having to support, house and care for smokers who perished prematurely from tobacco-related illnesses. A homo economicus view of health would give high rating to diseases that killed people quickly and in large numbers after their economic productivity ceased around 60 years. Such thinking is of course little different to that used by Nazi camp guards in pulling inmates out of work duty for execution when their camp productivity fell off due to illness or starvation. If prevention saves the state money, that’s a bonus. If it allows people to live a decent life span free of preventable pain, degraded health and able to move about in the community, most think that’s what good health policy should be all about.

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5 thoughts on “Actually, preventative healthcare has been a spectacular success

  1. stephen henry

    Bernard Keane is a good thinker and writer, but I disagreed with the idea that cure is cheaper or better than prevention.
    Simons last two paragraphs sum up the counter argument very well.

  2. bakerboy

    Good article, Professor. Being a mere left leaning journo, Bernard just doesn’t want to understand the facts sometimes. Of course prevention works and is worthwhile for most people. Smoking is the best example – my younger brother smoked 2 packs a day for 30 years and used to claim that there was no proven connection between smoking and lung cancer. Then at age 50, we had to watch him slowly die from cancer and emphysemia. The time will arrive when people who abuse their bodies will be given lower priority for treatment and have to pay more for it. Alex

  3. Roslyn Pike

    Professor, Sir,
    Thank you very much indeed, for a really good news story.
    All the best,

  4. Liz45

    A most informative article. Sadly, the growing incidence of violence against women and children from Domestic Violence didn’t rate a mention. According to PM Kevin Rudd, the anticipated cost to the country in the next financial year is $13 BILLION. He announced an injection of over $40 million next year to try and stop this shameful and damaging situation. The biggest threat to the healthy lives of women between the age of 19-45 is domestic violence. I’m not even sure that the $13 billion mentioned by Kevin Rudd covers all aspects of these horrific crimes – health, judiciary, police involvement, setting up a new home, time off school and work, psychological and or psychiatric care, womens’ refuges and associated costs. Not to mention the physical and psychological injuries that rate from mild to severe or life threatening.
    In Australia, 1 in 4 women are abused in their homes. It’s anticipated, that 1 in 3 women will be abused in their life time. Most of the homicides of this nature occur, after the woman has left the home. 75 women, that’s 1 every 10 days is murdered by a male person who purports to love her.

    This shameful situation is totally preventable, we just need to change the attitudes of those men who think it’s acceptable to abuse women and kids. This change in attitude must take place prior to the child being born – it’s the ingrained sexist views of the ‘treatment’ or ‘rights’ of boys and men that places women’s lives in jeopardy in their lives. Too many women experience their first act of violence during pregnancy. Any child who even hears violence in the home is a victim of child abuse. Too many victims of child abuse grow up to be perpetrators or victims.

    The first thing that must happen, is for the community to engage in discussion. For too long, the incidence of domestic violence has been treated as ‘secret and shameful family business’ – this must cease. For too long, women have been made to feel shame and guilt for being abused – this must cease. Crimes of sexual and physical abuse are the only ones where the victim is made to feel guilty. Too often, people are given more sympathy over their car being stolen, than a woman whose daily life is threatened by physical and or psychological abuse.
    Ridding our country of this scourge will add billions of dollars free, to be spent on other areas of health. Rather than ignore it or speak in hushed tones, only adds to an already costly and shameful reality for too many women and their children.

  5. Luke S

    very well argued. I normally agree with most of what Bernard has to say but I didn’t on this. It’s important to begin by saying that health isn’t the absence of disease. A salutogenic approach to this topic hinted at by the author in the last para is the pivotal point of distinction.

    Trouble is that ‘well-being’ is hard to measure if it extends beyond reduced contact with the health care system. I’m a health economist and can say that the profession (or at least a significant branch of it) is locked in a rigid, orthodox mindset when it comes to evaluating interventions. These reductionist methods (rg CBA or CUA) are dodgy enough when trying to evaluate the ‘net benefit’ of a certain medicine. Holding all possible factors and variables steady (the ceteris paribus assumption) becomes close to impossible when trying to measure the economic effect of ‘preventive interventions’. My univesity professor used to say ‘it’s better to be vaguely right than precisely wrong’. The studies cited by Bernard are definitely in the latter.

    The other issue here is that ‘preventive intervention’ is an oxymoron. If it’s an intervention it’s not prevention. It makes me laugh reading that cholesterol controlling medication is classed as prevention. It’s a treatment! True prevention in this case would be empowering individuals or groups to lead lifestyles and foster dietary habits that maintain safe cholesterol levels, perhaps with some medical advice. Some may still need cholesterol meds – that isn’t prevention, though. I suspect pharmaceutical companies like to label most of their products as preventive – it’s great for sales.

    We need to move beyond this mindset and accept that true prevention or, preferably, health promotion strategies lie in the very fundamentals of how societies are structured and organised. This goes beyond sanitation adn clean water (at least in developed countries) and reaches straight into the realm culture, social structure – the political economy. There is more and more evidence emerging that a certain type of economies produce happier and healthier people. That’s where the real action is at.

    For starters, however, it would be good if we could eradicate terms like ‘preventive health’ from the medical lexicon…..

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