No-one in their right mind would disagree with the proposition that it is better to prevent illness than to manage it. Why, then, is there not a stronger and more pervasive demand from the public for governments to shape their investment in health to match this commonsense approach?
Part of the answer lies in the language used – the imprecise and varied ways in which the prevention of illness is described and considered.
For there to be a consensus on the matter, there needs to be clarity and shared understanding about what is entailed. Language is important if agreement is to be reached and expressed by both those directly involved in the health sector and other members of the public.
It does not help to have discussions built haphazardly around terms as loose and diverse as ‘illness prevention’, ‘health promotion’, ‘preventive’ or ‘preventative health’, ‘public health’, ‘preventive medicine’, ‘preventable illness’ or (most nonsensically of all) ‘health prevention’.
So the first thing that could be done to increase support for the cause would be for everyone who writes and speaks about it to be more careful with the terms used.
From a semantic point of view, ‘health promotion’ and ‘illness prevention’ seem to be synonymous. It’s a zero sum game: the more health, the less illness. This should be the focus of efforts in the sector.
(I propose a plebiscite on which of the two terms is preferable. Its result would be binding on everyone who works, thinks, talks and writes on the matter.)
Both health promotion and illness prevention are processes through which people are enabled to increase control over, and to improve, their health. The terms encompass a wide range of social and environmental interventions by governments and other agencies, as well as individual behaviours and their modification.
‘Preventive medicine’ is a useful term, but professionally narrow. It means work by medical practitioners at the individual, community or population level to protect, promote and maintain health and wellbeing by preventing disease, disability and death.
‘Public health’ and ‘population health’ really have no place in this particular lexicon. ‘Health promotion’ and ‘illness prevention’ are high order (or collective) terms for a wide range of actions with the same purpose: to keep people healthy. In contrast, ‘public health’ and ‘population health’ are methods or approaches, within the health domain, through which interventions can be effected. The former means the health of the population as a whole, especially as monitored, regulated and promoted by the state. The latter is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.
This piece is not about to dignify, through discussion, the terms ‘preventive health’, or worse still, ‘health prevention’.
The relationship between these entities can be illustrated through both their accurate and inaccurate usage.
“The fluoridation of drinking water is a public health measure through which people’s (oral) health is promoted and (oral) illness prevented.”
“Ante-natal care is a population health measure (for pregnant women and their partners) through which their health and that of their babies can be promoted.”
In his address at the National Press Club on 17 August, Michael Gannon, President of the Australian Medical Association, said that people can be kept well and out of hospital “by greater investment upstream in public health prevention”.
And after a summary of Australia’s world-leading work on reducing the rates of smoking, Dr Gannon said: “We are a world leader in this area of health prevention”
Such slips of the cursor are not helpful to public understanding or support.
Given the more precise use of terms suggested, what can be said about Australia’s position on the matter?
The Australian Institute of Health and Welfare has reported that, in 2011-12, 1.7 per cent of total health expenditure went to public health activities, which included prevention, protection, and promotion. And according to the Prevention 1st Alliance that was active during the Federal Election Campaign, this proportion has been falling.
The Australian National Preventive Health Agency was abolished in the 2014-15 Budget, as well as the National Partnership Agreement on Preventive Health. Savings of $368 million over four years were transferred to the Medical Research Future Fund.
These cuts jeopardised initiatives such as community healthy lifestyle programs like the Heart Foundation’s walking groups and the Diabetes Council’s BEAT IT program; Healthy Children, which provided funding to states and territories to run physical activity and healthy eating programs for children in schools, early childhood centres and preschools; and Healthy Workers, which funded workplace programs on healthy eating, physical activity, smoking cessation and reducing harmful levels of alcohol consumption.
It is not clear what leadership and other resources are now being invested in these and similar endeavours by the Department of Health.
Australia’s 1.7 per cent on health promotion compares with New Zealand’s 6.4 per cent and Canada’s 5.9 per cent.
The OECD estimates that about half of all premature deaths are attributable to preventable behaviours, such as tobacco smoking and excessive alcohol consumption. Type 2 diabetes and cardiovascular diseases are also largely preventable, as are many forms of cancer.
The failure to invest adequately in health promotion is part of the reason for continued increases in the prevalence of obesity. Australia faces the prospect that the current generation aged 60-plus will have a higher average life expectancy than their children.
Being high order terms, health promotion and illness prevention activities take place in multiple settings, and through a range of policies: educational, social, economic, cultural, housing, environmental, transport etc.
Place is an important determinant of the prevalence of the health risk factors through which health promotion and illness prevention operate. One of the main ways in which health promotion is effected is through behaviour change. This means that the design and operation of health promotion interventions have to account for differences in the dynamics of behavioural change between groups of people in particular places, demographic groups, health condition groups, and economic or social circumstances.
A greater proportion of people in rural and remote areas are daily smokers than is the case for those in metropolitan areas. The extent to which this is due to the lower success rate of quit-smoking campaigns, as distinct from other causes, is unclear. But it is a very serious matter where the prevalence of poor health is concerned. And however important a contributor they are, there needs to be a better understanding of the effectiveness of health promotion campaigns in rural areas relating to the use of tobacco.
As can be seen, there is a great deal to be considered where health promotion is concerned.
The work should be informed by clear and consistent use of terms. This will help the public to appreciate the importance of insisting that more is invested.
And governments can be made accountable for their action and inaction on the best way to reshape the overall system so that it can be more concerned with health than with illness.