Portal de Periódicos da CAPES

Prevention Policy

2020; Project HOPE; Volume: 39; Issue: 4 Linguagem: Inglês

10.1377/hlthaff.2020.00239

2694-233X

L. Jonathan Cohen,

Public Health Policies and Education

Book Review Health AffairsVol. 39, No. 4: Integrating Social Services & Health Prevention PolicyLarry Cohen AffiliationsLarry Cohen ([email protected]) is a California-based prevention advocate and consultant in prevention strategy and policy nationwide. He founded Prevention Institute and was its executive director for two decades. He is the author of Prevention Diaries (Oxford University Press, 2016).PUBLISHED:April 2020Free Accesshttps://doi.org/10.1377/hlthaff.2020.00239AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSPublic healthDiseasesClinical careMedicaidPandemic preventionIt’s affirming to see two books on prevention—Prevention First, by Anand Parekh, and Upstream, by Dan Heath—come out during this election period. Providing health services to the entire population has been among the top issues politically, but the focus has been almost entirely on the care side and the related costs of doing so. The enormous potential of prevention to save lives and misery, reduce demand, and reduce cost hasn’t been given any noticeable lip service, let alone an emphasis as an essential part of the solution.These two books are quite different, but potentially complementary, in their primary target audience and approach. Upstream is written for the general public, including thought leaders and influencers, and is not specific to health. It reminds people of how obvious and beneficial prevention approaches can be in fields such as business, education, and ecology, as well as health. Prevention First is clearly aimed at health leaders, policy makers, and people deeper in the weeds of making health happen, and it provides more specifics on implementing prevention efforts.It is clear from both books that politicians are missing an easy opportunity. The commonsense nature of prevention is appealing. It can make the politician who emphasizes prevention sound more down-to-earth, practical, and humane at a time when a lot of health care solutions might sound complicated and scary. The fact that many prevention strategies save money can make any expansions of health services more palatable and financially viable. Prevention, as both authors describe it, is more than just individuals taking care of themselves and their families: It’s a way of thinking broadly about the concept of before. I hope that these books encourage further dialogue on systematic change.Dan Heath, with his brother Chip, authored four previous “concept books,” including Made to Stick and Switch. Each expresses the common sense and inner working of a set of ideas and encourages the scaling up of effective approaches. Upstream emphasizes the notion of making change at multiple points along a continuum as you look back at the creation of a problem. By using the term upstream rather than prevention, Heath highlights not only the fact that you can do important prevention work after a problem arises, but also that you can go back very far—farther than many primary prevention initiatives go—to the structural, community, and environmental conditions that eventually result in problems.Upstream starts with prevention advocates’ persuasive parable about children nearly drowning in a river one after another, and a rescuer finally going upstream to find out why the children ended up in the river in the first place. The first real-world example in the book discusses the travel website Expedia’s problem of receiving follow-up customer service calls for nearly 60 percent of the travel booked on it. Analysis revealed that the most common issue was that people were not receiving their travel itineraries. So Expedia designed solutions both to preempt many of these problem calls and to resolve the others easily online—primary and secondary prevention, you might say. “Surely we would all prefer to live in the upstream world where problems are prevented rather than reacted to, so what holds us back?” Heath asks. He interviews health leaders and, using his outsider vision and skill at synthesis, provides answers to his question. For example, he describes tunneling, the phenomenon in which a constant focus on urgent demands has people “dug in” so they can only see forward and are virtually obstructed from scanning for broader visions and options. He then lays out what he considers necessary ingredients for looking upstream and maximizing prevention progress.Heath layers numerous stories from diverse fields to reveal the potency of the strategies he has uncovered for effectively preventing problems from arising. Topics include blind auditions, a systems change that led to more women being hired in orchestras; DonorsChoice, an education project fund-raising site that he suggests could leverage its huge number of supporters to advocate for greater investments and government support for education in general; and failing ATMs and how different interpretations of why they fail could lead to very different implications and thus impacts. Returning to health, he tells the memorable story of Bob Sanders, a physician who was instrumental in passing the Tennessee law and subsequent state laws that require infant car seats, referring to an amendment that would have allowed an adult to hold a baby in their arms in the car as the “Child Crusher,” rather than the “Babes in Arms,” amendment.Heath takes the unusual step of presenting some of his most important findings about prevention as questions rather than assertions. For instance, how do we know where to concentrate prevention efforts and what levers will make success likely, how will we determine whether (and how much) success is being achieved, who are the most important partners and how can we best bring them together, and who pays for something not to happen? To me, this signals that prevention is still an emerging craft, a mix of science and art, and that careful thought is needed to foster prevention success. I appreciate this, though at times I wished Heath would have been more crisply declarative. Many of the strategies are clear and well founded. We just need to put them into broad practice. Heath is definitive about systems change, stating that “part of every social service organization’s mission should be to push upstream.”Parekh’s Prevention First, in contrast, is primarily based on the author’s immersion in the world of prevention, health, and medical care. The Bipartisan Policy Center, where Parekh serves as chief medical adviser, is one of the most constructive voices for national health solutions in the US. The foreword, cowritten by former Senators Bill Frist (R-TN) and Tom Daschle (D-IA), states that “prevention has been underfunded and undervalued by government leaders for far too long.” The book is divided into two sections: “Prevention Within the Healthcare Setting” and “Prevention Outside the Healthcare Setting.” Parekh emphasizes that the US strategy toward health (like many things) is overly reactive, considering problems critical only after they emerge. The book’s specificity is part of its value, including citations to some of the studies that show the wisdom and cost-effectiveness of numerous prevention strategies and a discussion of the role of the Center for Medicare and Medicaid Innovation (CMMI) as an engine for developing and spreading innovation—including in the field of prevention.In the “within the health care setting” section, Parekh details how incentives need to be realigned so that efforts to keep people healthy emerge more forcefully. In the “outside the health care setting” section, he describes how multiple sectors, often led by public health, can play a role in creating a culture that encourages prevention.Parekh describes the book as being about preventing disease, not injuries. That is surprising, as injuries are a major contributor to poor health—probably as much as diseases are. In fact, according to the Centers for Disease Control and Prevention (CDC), injuries are responsible for nearly 60 percent of all deaths in the US among people ages 1–44. Injuries are at times more easily preventable than diseases, and injury prevention brings in an additional strong constituency to prevention efforts. Injuries provide some of the best examples of how straightforward and cost-effective prevention can be, from car seats to safety caps on medicines. Perhaps Parekh considers it easier for readers to grasp disease prevention more narrowly, or perhaps some injury prevention strategies are politically controversial—such as gun control efforts. He does discuss injury prevention occasionally (referring to traffic safety and prevention of falls and suicide), although his earlier wording about the book’s central focus implies otherwise.A physician, Parekh progresses from simpler and more medically oriented prevention solutions to broader communitywide and systemic approaches. Starting with the medical side makes sense, as it will take medical credibility and leadership to achieve the culture of prevention that Parekh advocates. We saw this with smoking, where it was doctors—whose financial interest in treating the downstream effects of smoking was arguably hurt by opposing the use of tobacco—who convinced politicians that we needed tobacco restrictions and regulations. Public health and nonprofit organizations marshaled and organized the approach, but it wouldn’t have worked without the white coats alongside.Particularly in the health care section of the book, Parekh tends to stay more anchored in the traditional medical model—focusing on one person at time—and a good deal of his prevention emphasis is after the onset of illness. For instance, he describes the CMMI bundled payment initiative as a way to get people out of the hospital sooner, creating more efficiency and saving costs, instead of focusing on ways to prevent medical incidents. Later, however, he makes it clear that comprehensive systems change is also a priority. One chapter focuses on social determinants of health, where community and national policies and practices on issues such as transportation, food, and housing could have some of the most extensive impact on reducing care needs. He returns to this notion in the “outside health care” section, where he describes the impact of the CDC’s Communities Putting Prevention to Work program, a major effort to promote communitywide health-oriented partnerships. The initiative increased forty million Americans’ access to physical activity and nutritious food. Scaling such efforts up can reduce illness and injury in the first place.The epilogue of Parekh’s book underscores five overarching strategy recommendations for policy makers, and it is powerful and persuasive. First, current and future administrations must make prevention the number-one priority as manifested in strategic planning efforts and budget submissions to Congress. Second, consistent with value-based health care transformation, health care professionals should be incentivized and held accountable for preventing chronic diseases. Third, a regulatory pathway should be created to expand and scale up evidence-based community prevention programs. Fourth, targeted investments should be made in the US to support community prevention efforts, the public health infrastructure, and a public health emergency fund. And finally, the nation’s health research enterprise must increase prevention research, spanning biology, behavior change, and policy implementation.In Upstream, Heath says that he hoped to raise the volume regarding prevention. Both books enhance the volume, the vigor, and the vision. I hope the audience is large—and listening. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Health Affairs may receive a commission for purchases through links. We appreciate your support of Health Affairs! Article Metrics History Published online 6 April 2020 Information© 2020 Project HOPE—The People-to-People Health Foundation, Inc.PDF download