Prevention Science and the Academic Public Health Agenda.
Before I start today’s note, I just wanted to reflect for a moment on the devastatingly sad shooting in South Carolina at Emanuel AME Church. As of this writing, this tragic incident seems to very much reflect an intersection of issues I have raised before in these notes, including hate, firearm availability, and racism. That such incidents keep happening is a bracing reminder of the urgent, insistent need for repeated articulation of the centrality of these forces to the production of health, and the imperative for societal action to address them.
Moving on to today’s topic. Prevention approaches have the potential to minimize morbidity and mortality, and to save substantial cost in curative care. A Centers for Disease Control and Prevention analysis of National Vital Statistics System data from 2008 to 2010 showed that 91,891 deaths from cardiovascular disease, 84,539 from cancer, 28,853 from chronic lower respiratory diseases, 17,062 from cerebrovascular diseases, and 37,016 from unintentional injuries potentially could be prevented each year if all US states achieved the lowest three states’ average mortality. To put that in perspective, this analysis suggests that more than a quarter of all deaths from these five leading causes of death can be prevented. This assumes that states with the lowest mortality in the US are the gold standard, which is, of course, far from the case. We know that health indicators in the US lag substantially behind other high-income countries, suggesting that there are other approaches that we can take to prevent disease and minimize premature death that are not currently being adopted in the US. In addition, a simple review of the data amassed in the US Preventive Services Task Force recommendations suggests that we are far from adopting the best available strategies to prevent morbidity and premature mortality. Therefore, potential premature mortality averted in the US is almost certainly greater than that suggested by this one analysis. It also bears mentioning that the analysis tells us little about the benefits that we can accrue as a society by preventing disease before it starts.
All of which is to say that the benefits of preventive approaches are large, and that we stand to gain tremendously as a society if we made a concerted effort to invest in preventive approaches. Prevention stands at the heart of population health, wherein we aspire to prevent disease, reduce risk, and shift the need away from curing disease once it has already happened.
It has been lamented frequently, and eloquently, that we, as a society, invest far less in prevention than we might and should. Others have written eloquently about the challenges we face in promoting prevention. Most notably to my mind, a paper by Harvey Fineberg suggests that the core challenges to a prevention approach are that success of prevention efforts is invisible and lacks drama, statistical lives have little emotional effect, and benefits often do not go to those paying for prevention even as prevention is expected to produce a net financial return. Fineberg also offers potential solutions to these challenges: aligning incentives so that clinicians are paid for preventive care, incentivizing prevention, engineering societal nudges to favor prevention, and using media to educate around prevention. While one could add to, or edit this list, by and large I think it captures well the challenges we face in adopting prevention approaches more broadly and represents reasonable approaches that might, if implemented, result in broader uptake in prevention efforts in the US. I wanted here to comment, from the perspective of academic public health, on the potential of our work as a school to contribute to this effort.
Specifically, what role do we play in advancing prevention?
I would argue we have roles to play here, consistent with our vision for ourselves, in each of the three areas of action in which we engage as a school.
We generate knowledge. This suggests that one of our core roles is in the promulgation of scholarship around prevention science, in identifying the open questions that we could tackle that, if effectively addressed, would move a universal prevention agenda forward. I suggest that open questions in the field follow the following lines. First, the evidence base for the efficacy of primary prevention efforts remains astonishingly weak. In part this is because many primary prevention efforts are never formally evaluated, or if so, done so poorly. A growth in the evidence about efficacy of primary prevention efforts can lead to work on the effectiveness of these approaches, and to an evidence base that can compel action. Second, and a particular case of the former, the evidence for macro-level efforts at prevention and their impact in the long-term is vanishingly small. Population health science thinking suggests that upstream interventions stand to influence the health of populations, but these efforts suffer from empiric evidence. Natural experiments of political and structural preventive efforts, and their long-term effects stand to illuminate the field. What are the lowest-cost approaches to prevention that yield as much benefit as possible during the lifecourse? Third, arguments for the financial salability of prevention efforts rest of return on investment analyses, and a demonstration that prevention efforts yield benefits, across sectors, that well repay investment. Fourth, while the marriage of public health and cognitive neuroscience has emerged recently, its application to prevention efforts remains nascent. How do we effectively communicate the benefits of prevention to a population far more accustomed to thinking about the individual benefits of curative approaches? Fifth, what would be innovative approaches to prevention? How do we, for example, prevent alcohol misuse among high-use and vulnerable populations? Sixth, the little literature we do have around the effectiveness—and return on investment—of prevention approaches comes from high-income countries. The global extension of these data, to enable us to understand how different approaches may have greater benefit in different countries, could extend the footprint of prevention approaches globally. While our research questions are driven, perhaps too often, by the resources available to fund them, clarity around the questions we should be asking remains a prerequisite for our capacity to conduct scholarship of consequence.
We transmit knowledge to our students. As we think about how we educate the next generation of public health professionals, it falls to us to think critically about how we can infuse thinking about prevention as a core value that animates our curriculum and prepares students to engage in innovative prevention efforts during the course of their careers. While this suggests the development of particular educational modules that focus on prevention, it perhaps agitates more for the introduction of prevention as a foundational focus of public health, infusing all our educational offerings. It might also encourage an investment in efforts that guide our students to develop an innovation armamentarium that can serve them in good stead during their careers as they engage in efforts to promote health through preventing diseases. Ultimately, this suggests that our educational efforts need to carefully prepare students for the growing heterogeneity of occupations in which they are engaging upon graduation, considering how students who work across sectors can meaningfully engage different aspects of prevention.
We translate knowledge to those who can make change happen on a global scale. While there is little doubt that our evidence base on prevention science remains limited, it is also clear, as evidenced by the example I opened this essay with, that the gap between what we know and what we do looms large. We are the keepers of what we know, and it falls to us to develop approaches that can bridge this gap. This places a premium on us not simply to generate the right knowledge, but also to identify how to convey this as clearly and compellingly as possible to the broad range of constituencies who can implement prevention efforts. This, definitionally, involves communication efforts that are cross-sectoral—that engage government, non-governmental organizations, and industry, all of which take part in some element of a comprehensive prevention agenda. As I have noted in other Dean’s Notes, this third arm of our mission is perhaps the newest and least familiar of our goals, but it also might have the best potential to achieve short-term success, bringing prevention efforts that we should be implementing to light even as we engage more deeply with prevention scholarship and steep our students’ education in an appreciation of the foundational role that prevention plays in public health.
I look forward to engaging further around prevention science in our scholarship, teaching, and translational efforts.
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
@sandrogalea
Acknowledgement: This Dean’s Note is based in part on a body of work developed in partnership with Dr. Abdulrahman El-Sayed.
Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/