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Key messages

  1. Changes in the social, economic and political environment can lead to substantial changes in health and health risk.
  2. Different approaches to prevention and intervention have differential population impacts.
  3. Interventions need to be multi-level and work on strengthening individuals, communities, improving living & working conditions, encourage macro-economic and social change to improve health and reduce health inequalities.

Motor vehicle crash deaths

  • Enormous difference from 1983 to 2002 in rates of particularly young males' death rates in car accidents
  • If we continued the graph out 10 more years, the graphs would stay flat
  • Equity: is the big sex difference about biology or about social inequity?
    • There is still a gap even though it has closed substantially
    • Big driver is social pressures - pressure to drive fast amongst males

Around 50% decline in young males – causes

  • Changes in road design
  • Improved safety features in cars
    • ABS, seatbelts, crumple zones
  • Active enforcement by police
    • Random breath testing
  • Mass media campaigns
    • Campaigns against speeding (shock campaign)
  • Improved retrieval & medical care

Note that driver education doesn't matter at all to the rate of accidents (in fact it increases your risk of accidents) - due to overconfidence (false sense of security)

Potentially avoidable mortality

  • For every 100 deaths from ischaemic heart disease (IHD)
    • 50 could be avoided through primary prevention
    • 25 could be prevented by secondary prevention
    • 25 could be prevented through tertiary prevention
  • A key preventive point is having enough disposable income, so that if something significant happens in your family (e.g. lose the breadwinner for several months) you can cover that cost. This is as potent a risk factors as smoking etc.

Primary, secondary and tertiary prevention

Level Definition
Primary prevention Methods to avoid occurrence of disease.[1] Most population-based health promotion efforts are of this type.
Secondary prevention Methods to diagnose and treat existent disease in early stages before it causes significant morbidity.[2]
Tertiary prevention Methods to reduce negative impact of existent disease by restoring function and reducing disease-related complications.[3]
Quaternary prevention Methods to mitigate or avoid results of unnecessary or excessive interventions in the health system.[4]

Graph of potentially avoidable mortality and intervention

Sleep deprived doctors

  • Told to get a coffee
  • Fix things on the run rather than preventing it by sleeping enough
  • Also asking doctors, who are sleep deprived and hyped on caffeine, needs to petition managers to sort out their hours for them. This is stupid - it should be done from the top down. The thinking is endemic throughout the system. The medical board chairwoman is saying ridiculous things in this article.

Potentially avoidable deaths by SES

  • Potentially avoidable death = anyone <75 years that died of a condition that can be clearly related to a lifestyle choice (i.e. preventable)
  • This graph has split the population into quintiles, taken out the richest 1/5, poorest 1/5 and lumped together the rest.
  • Gap between highest and lowest has become smaller over time, but it's still there
  • The difference between the "low" and the "rest" is not much at all.
    • Therefore the difference between the top tier and the next tier is quite big
      • This includes professionals - even those of us who have gone through a lot of education etc are much more likely to die than the true-blood rich.

The health gap: is it shifting?

  • The greatest health gains in health across the population will be in improving the health of the middle 60% and lowest 20%
  • But evidence suggests that the typeof programs we promote may be advantaging the advantaged
  • Reason - things we have done to improve health of the population
    • Medicare
    • Mass media campaigns (e.g. 'how do you measure up?' - social marketing campaign)
      • These campaigns don't talk to everyone across society the same. Younger people tune out immediately if it's got an old person. Poorer people prioritise other things in their lives over these messages
  • We need enough different types of strategies that the same message is being reinforced across the population

Role of the health system? CVD example

  • Population screening approach (lifestyle advice or medication for high risk) typically widens socioeconomic inequalities
    • Inequalities in screening, healthy diet advice, smoking cessation, statin & anti-hypertensive prescribing, adherence
  • Alternative approach is population-wide CVD prevention
    • legislating for smoke-free public spaces, banning dietary trans-fats, or halving daily dietary salt intake
      • e.g. Denmark has a fat tax but they got rid of it since it was so hard to regulate it (e.g. high-fat quality cheeses): this DIDN'T work
        • but smoking in Australia did!

Case Study: Tobacco (then)

  • Marlboro Man
  • Major sporting events sponsored by tobacco companies
  • Smoking in public transport, planes, offices, movie theatres
  • Doctors smoke
  • Relatively low cost
  • Tobacco growing, retail and advertising a significant part of the economy
  • Smoking seen as sophisticated and every home had an ashtray

Case Study: Tobacco (now) - a success

  • Smoking advertising banned
  • Plain packaging & hidden at point of sale
  • Nicorette in Sydney to Hobart
  • Effective smoking bans in clubs, pubs, transport, workplaces
  • 99% of doctors do not smoke
  • High cost
  • Potentially high cost of litigation
  • Tobacco companies diversifying their economic base
  • Increased stigma attached to smoking and exposure to secondary smoke

Potential targets for public health programs

  • Ecological model of health

Strengthening individuals

  • A lot of these public health programs require individual motivation, which we must boost. Even though PBS supports a lot of these (e.g. Nicorette), it requires their motivation first.

Strengthening communities

  • BUGAUP - group who changes billboards to prevent unhealthy behaviour
  • Messages target different people

Improving living and working conditions

  • "No Smoking" and stigma

Encouraging macroeconomic & cultural change

  • Plain packaging, and hidden at the point of sale

It’s up to you!

  • The impacts of the social and economic environment on health is something you will see everyday. In the public health system your work will be more effective if you take the opportunities to strengthen the capacity of patients to prevent and manage their health problems
  • Because of the role of doctors in our society you will be well placed to advocate for change
  • A commitment to changing the social and economic determinants of health is value laden and often unpopular – it requires champions
    • Like climate change today


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  4. Gofrit ON, Shemer J, Leibovici D, Modan B, Shapira SC. Quaternary prevention: a new look at an old challenge. Isr Med Assoc J. 2000;2(7):498-500.