PREVENTIVE

MEDICINE

4, 387-389

(1975)

EDITORIAL

Prevention:

The Only Cure

WALTER W. HOLLAND, M.D. Department of Community Medicine, St. 1 homas’s Hospital Medical School, London, England

That prevention is better than cure is a sentiment with which most would concur. But how effective is preventive medicine at this time, and where should it-be going in the last quarter of the twentieth century? The great advances in this field in the western world date from about the middle of the nineteenth century and were largely concerned with the improvement in environmental services, particularly housing and the water supply. But, in recent years, prevention has become less dramatic and more complex and it is important to be quite clear as to what it means. There are three separate forms of preventive medicine, each requiring different tactics. Primary prevention implies the removal of the underlying cause of a disease or group of diseases- the removal of bacteria from water to prevent waterborne diarrhoeal disease. Secondary prevention involves the diagnosis of a disease at a stage where successful treatment can be given and death avoided-the detection of silent shadows on mass X-ray leading to early treatment of tuberculosis. Tertiary prevention concerns the identification of individuals with a condition which cannot be cured or reversed but whose consequences can be alleviated or improved- the provision of spectacles for those with visual defects. In the United Kingdom and the United States-to which these remarks are confined- the five most common causes of illness and death today are cardiovascular disease, particularly coronary heart disease and other forms of arteriosclerotic degeneration, chronic respiratory disease, particularly chronic bronchitis and emphysema, all forms of cancer, psychological disease including depression and the psychoses, and accidents. This change in disease incidence from the time when infective diseases were rife to the present situation has important implications for preventive methods. In the past, it was possible to prevent major mortality and morbidity by relatively simple governmental or public health action on water, nutrition, and housing. But the underlying causes of today’s “top five” disease categories are quite different. Most of the conditions in question are linked to aspects of personal behavior, smoking cigarettes, driving cars, drinking alcohol, lack of physical exercise, and so on. And personal behavior is extremely difficult to influence. Theoretically, people could be forced by law to stop smoking cigarettes or to take exercise but this would involve a 387 Copyright @ 1975 by Academic Press, Inc. All rights of reproduction in any form reserved.

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level of interference with personal freedom unacceptable in our present society. We must, therefore, try to develop different and more subtle preventive techniques. There are some very simple measures which merit serious consideration. All health personnel, for example, ought to be aware of the hazards of certain practices such as smoking and excessive drinking, and could be strongly encouraged not to indulge in these publicly. Similarly, “no smoking” rules in public places could be extended. Perhaps one of the greatest barriers to effective action of this nature has been the ignorance or indifference of lay decision makers on the consequences of certain activities. Hopefully, the recent reorganization of the National Health Service in the United Kingdom, bringing all health matters including prevention and education under one authority, will make it possible to influence such people by the concerted action of all those responsible for health services. It is also important to clarify what forms of preventive action are likely to be most useful. More recent work has suggested that secondary prevention- screening for early disease-is not helpful in preventing the development of most of our major diseases. And it is surely time to face the futility of most presymptomatic screening at present, and to improve on primary and tertiary prevention which may be more effective. In primary prevention, for example, we should attempt to identify and influence individuals who smoke cigarettes, are overweight, take little exercise, and so on. This could be done at the primary care level-the general practitioner is still in a powerful position to influence his patients and, with the aid of other health services personnel, such as nurses, social workers, and health visitors, his advice to those with damaging habits might be more effective. Levels of blood pressure in children do appear to be influenced independently by weight and by level of blood pressure in their parents (1). It has also been demonstrated (2) that cigarette smoking by parents does influence the incidence of respiratory illness in newborn babies. Thus, elevated parental blood pressure, for example, could be used to identify children at greatest risk and we could try to ensure by discussion and advice that they do not become overweight or start smoking. Tertiary prevention likewise has an important and undervalued role. The provision of services for those with visual and hearing defects or those requiring chiropody is inadequate; and an improvement in this rather unglamorous area could have a much more profound effect on the quality of life for many people than more exciting forms of intervention such as heart surgery. It is time preventive medicine came to terms with current patterns of disease and tried to modify the personal behavior of those at particular risk rather than to attempt to change the behavior of whole communities. The conventional methods of health education-poster campaigns, lectures, exhortations from experts-directed to the public at large have not proved very successful. It is possible that relating and explaining a specific risk (lung cancer) to an individual with a particular habit (cigarette smoking) would have more ef-

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THE ONLY CURE

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feet. And it is important that we try-after all, for most of the major modern causes of illness and death, prevention is the only cure. REFERENCES 1. Beresford, S. A. A., and Holland, W. W. Factors influencing blood pressure in children. 2nd International Symposium on the Epidemiology of Hypertension, Chicago, September, 1974. 2. Colley, J. R. T., Holland, W. W., and Corkhill, R. C. Influence of passive smoking and parental phlegm on pneumonia and bronchitis in early childhood. Lancet 2, 1031 (1974).

Editorial: Prevention: the only cure.

PREVENTIVE MEDICINE 4, 387-389 (1975) EDITORIAL Prevention: The Only Cure WALTER W. HOLLAND, M.D. Department of Community Medicine, St. 1 homas...
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