Learning about Prevention.
Before I start today’s Note, a moment’s pause to reflect on the dismaying language endorsing racism towards and exclusion of Muslims taken by a leading candidate for nomination for president. The consequences of racism and hate for health abound, and the consequences of such a regressive turn in public discourse are too disheartening to contemplate. I have previously argued that we have a responsibility to embrace a range of opinions in order to promote values that contribute to a healthier world, but it well passes beyond the realm of reasonable to countenance public statements that can contribute to a culture of hate. I thought John Cassidy’s piece about this to be right on—suitably illuminating how hollow, sad, and dangerous this public show of demagoguery truly is.
On to today’s note. A few weeks ago I had the privilege of co-organizing a meeting about prevention science under the auspices of the Rockefeller Foundation. The meeting brought together academics, public health practitioners, and industry partners to discuss the state of prevention science worldwide and to identify key avenues to promote a primary prevention agenda globally. The meeting was informed by the recognition that although substantial improvements to population health can be achieved with the broad adoption of prevention efforts, the vast proportion of health spending worldwide is on curative care. For example, evidence from high-income countries demonstrates that health systems relying exclusively on secondary prevention and curative care often fail to meet the goals of reducing morbidity and mortality, despite extreme expense. In 2010, the US ranked 24th out of the 30 Organization for Economic Cooperation and Development countries with respect to life expectancy—driven largely by higher burdens of a number of preventable diseases, including diabetes, cardiovascular disease, and chronic respiratory disease as compared to other similar countries. However, Americans already spend far more on healthcare than any other country in the world. Between 2011 and 2015, 17.1 percent of US gross domestic product (GDP) was spent on healthcare. More importantly, healthcare costs have grown faster in the US than in any other country in the world over the past 40 years, even while the US spends 3 percent to 5 percent of its health expenditure on public health or preventive services. The Institute of Medicine put it succinctly in saying, “It is no longer sufficient to expect that reforms in the medical care delivery system alone will improve the public’s health. Large proportions of the US disease burden are preventable.”
There is little question that prevention has the potential to minimize morbidity and mortality worldwide and, in particular, that we can mitigate the burden and cost of non-communicable diseases (NCDs). The opportunity is particularly great in lower- and middle-income countries (LMICs), where upwards of 80 percent of the world’s burden is concentrated. Currently, nearly 8 million people die of NCDs before the age of 60 in LMICs annually, and the burden of NCDs is only expected to grow: Estimates suggest a potential increase in the burden of NCDs in LMICs of nearly 17 percent overall, and up to 27 percent in regions like sub-Saharan Africa.
With this background, the meeting aimed to capitalize on a growing recognition that a focus on primary prevention as a centerpiece to a functioning health system has the capacity to both decrease morbidity and mortality over the longterm and to afford health systems—particularly in contexts that may have limited resources—substantial cost savings.
The discussion was interesting and fruitful, and a white paper will emerge from the meeting that I will be glad to share. I have written here previously about prevention, so I will not also summarize either the literature or the state-of-the-science in the field. However, I did want to share five key learnings that I thought emerged from the meeting. While these ideas are not new, I found the discussion among a range of experts across sectors clarifying and helpful.
- An imperative for prevention: the consequences of inaction. The need for more attention to prevention is urgent, particularly in a rapidly changing health and healthcare environment. In particular, the emergence of newer blockbuster drugs emerged as a compelling topic of discussion. For example, Sovaldi, manufactured by Gilead, is a remarkable drug, capable of curing hepatitis C. About 500,000 people die from hepatitis C-related liver diseases annually. Sovaldi is (unsurprisingly) expensive, resulting in several calls for revisiting its pricing. Leaving aside the issue of drug pricing, the impact of Sovaldi and other emerging drugs on health care budgets begs the question: whither prevention? Hepatitis C is transmitted principally through drug use and is largely preventable. We know this, and yet have spent far less on known and effective harm-reduction efforts only now to face a far more expensive prospect—a treatment that is effective, but potentially ruinous for health systems locally and globally. This adds a strong argument to the imperative for prevention in addition to the inescapable ethical imperatives that at core must drive our interest in the area.
- The constraints on prevention. The challenges faced by efforts to introduce prevention remain strong and formidable. Centrally, these challenges are financial, political, and empirical. On the financial front, the costs of prevention are frequently borne by actors who do not reap their benefits. In the domestic system, a hospital, health system, or health department that implements a preventive program may be accruing benefits for a health payer who sees costs decrease but who is not involved in the original outlay. This mismatch challenges any one actor’s incentive to introduce preventive efforts and see commensurate return on the investment. Politically, the temporal lag between preventive efforts and the benefits that emerge from these efforts is too often a non-starter. Political actors are on a short timeline, with a desire to see yield from efforts they invest in within their term in office. Empirically, we have a remarkable paucity of good data about the efficacy and effectiveness of large-scale primary prevention efforts worldwide. This reflects the nature of many of these efforts, which are implemented by systems that are not accustomed to rigorous evaluation. Unfortunately this has left us with a limited body of data that we can use to muster arguments for more and better preventive efforts. This rather sad state of affairs was well-captured by Richard Foster, then Medicare chief actuary, who wrote, “There is no consensus in the available literature or among experts that prevention and wellness efforts result in lower costs.”
- Prevention as a link between the clinical and public health worlds. The opportunities for prevention are as extraordinary as are the constraints prevention efforts face. However, one opportunity that emerged clearly from the cross-sectoral discussion is that preventive efforts can serve as bridges between the clinical and public health worlds. This is true for primary prevention—which frequently involves direct implementation of efforts that engage with patients within clinical systems—but particularly so for secondary and tertiary prevention efforts that involve working with patients who have already been exposed to disease. Sticking with the case of hepatitis C, for example, secondary prevention of attendant liver disease involves regular monitoring and early use of antiviral drugs as appropriate. Similarly, and conversely, immunization against hepatitis A and B for persons infected with hepatitis C substantially minimizes hepatitis-related morbidity. These efforts blur the lines between clinical medicine and public health, forming a useful bridge between the two that can serve us well in this and many other areas.
- Private initiatives and innovation and technology. While we approach prevention as a core responsibility of public health scientists and professionals, innovation in prevention is increasingly emerging from sectors that have not traditionally been linked to public health. At one level, treatment as prevention brings the biotechnology and pharmaceutical industry into the fold. The emergence of pre-exposure prophylaxis has revolutionized HIV prevention, and emerging insights, such as the use of metformin in cancer prevention, will do much the same for other areas. More prosaic treatment efforts rest on the innovation in and adoption of new technologies. This extends as far back as innovations in bed nets to prevent malaria, but also extends forward to the application of genomic approaches to infectious pathogen analysis, identification, and vaccine development. Rapid diagnostic methods depend on technological development and present opportunities for prevention that were outside our armamentarium not so long ago. This is a strong argument for a multi-sectoral conception of public health that embraces industry, government, and non-governmental actors as partners in the production of population health and the prevention of disease.
- Strategic application of hidden government policy levers and restructuring of health systems. The constraints on prevention discussed here are real and reflect deep system-level barriers to more widespread dissemination of prevention efforts. However, much as these barriers exist, they depend on system incentives and structures, and those same incentives and structures can be leveraged to optimize the likelihood of prevention efforts being implemented and succeeding. For example, at the domestic federal level, the Office of Management and Budget (OMB) is responsible for budgetary projections for new policy implementation. However, OMB time horizons are time-constrained, limiting the analysis of potential benefits of longer-term efforts such as preventive efforts. This limitation therefore presents opportunities for seemingly unrelated policy lever re-engineering (i.e. lengthening OMB review window) that can have substantial import for prevention efforts. Similarly, such levers exist within health systems, and the architecture of health systems can and should be engineered to maximize preventive approaches, ranging from payment and reimbursement systems to individual physician incentives. Turning back to the introduction to this note, given a large, expensive health care system, failure to do this represents an enormous opportunity cost and an entrenchment in the curative status quo, with attendant poor health indicators.
I hope everyone has a terrific week. Until next week.
Warm regards,
Sandro
Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Twitter: @sandrogalea
Acknowledgement: This meeting was co-organized by Dr. Abdulrahman El-Sayed, and I am grateful for Dr. El-Sayed’s comments on this Note.
Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/
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