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.
- 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.