Prevention and cure

While organising notes, I stumbled upon this quote I bookmarked years ago, from the great Harvard cancer biologist Judah Folkman:

A pediatric surgeon in Boston just finished a difficult operation. To relax, he went to the Charles River and sat down on a bench. Suddenly, he heard cries of ‘Help! Help!’ and saw a person drowning. The surgeon jumped into the river and pulled the person to safety. He lay exhausted on the banks of the river and again heard, ‘Help! Help! ’ He glanced at the river and saw another person drowning. Despite his exhaustion, he jumped into the river and pulled the second drowning person to safety. Now, he was truly exhausted and lay on the ground huffing and puffing and again heard, ‘Help! Help! ’ He raised his head to look toward the river and saw a third person drowning, but he also noticed two basic researchers walking by the river. The surgeon shouted, ‘Colleagues, you must help! This is the third drowning person in the river in one afternoon! ’ The researchers looked at the river and then at the surgeon and said, ‘Three people drowning in one afternoon? This is very interesting! We’ll walk upstream to see who’s throwing them in!’.’’

(I think actually that it would work better if cast with public health researchers in place of basic researchers. The basic researchers would be too busy describing in obscure detail of the currents of the river, while translational researchers designed a better buoyancy aid for those currents.)

Folkman was applying the metaphor to his own field, cancer, but it works equally well for death and injury on our streets. The “road safety” approach to the problem has people studying the currents and advocating hi-viz vests and bicycle helmets, while spending billions on air ambulances and major trauma units. The “road danger reduction” approach goes upstream and asks why we are allowing large volumes of fast moving vehicles into the places where we live and work and play and learn. And it’s notable that in medicine, it’s the surgeons who think that preventing injury means bicycle helmets, and the public health researchers who think that preventing injury means calming and removing cars and trucks.

Here are a few of them: Danny Dorling talking about the open sewers of the 21st century; Harry Rutter’s Street Talk on moving towards a healthier city; and Ian Roberts, acting badly, on The Energy Glut. And you can hear Robert Davis talking about “road danger reduction” at London South Bank University on thursday next week.

During the 20th century, life expectancy lengthened by 30 years in the developed world. 25 of those years are attributable to public health intervention — to prevention rather than cure. But prevention disproportionately helps the poor and frequently hinders the rich. Guess which branch of medicine gets all the money.

4 thoughts on “Prevention and cure”

  1. Touche! The garbage collectors and those who keep our drinking water clean and maintain our sewer systems save millions more lives than doctors. I’m sure there’s other vital preventative workers going unsung that could also be mentioned in the former category, e.g. those who maintain our roads (and bike paths – does this happen outside of Holland and Denmark?) in a safe and trafficable condition.

    The medical profession, especially surgeons, are so overrated when it comes down to how many lives are saved. BTW this is not an argument to pay the “ordinary” workers a lot more money but it is one to pay the latter much less, with the money saved being put towards more preventative infrastructure such as separate cycling paths.

    1. Reminds me how undervalued hospital cleaners are. Ours have been on strike several times due to the company/trust not paying them what they’ve been owed in Southampton.

      People forget how important clean wards are, yet the common comment tends to be one of “if you don’t like it, go work for someone else!”

      There are clear problems with giving higher level public servants extreme wages, it takes money away from public services and tends to mean higher than necessary taxes.

      I think people are starting to question the way our public services are run, starting to see the knock on effects to things like road safety (eg lollipop ladies) and starting to wonder for the future of their kids and themselves when they become older.

  2. Could it be that the biggest prevention steps have already been undertaken?

    Maybe I’m relying on stereotype too much, but the biggest (though by no means only) factor in life expectancy growth was reduction in child mortality. Developed countries increased their life expectancy significantly by cutting infant mortality from 250 to 25; cutting it further to 2.5 does not have as big an effect. That was almost entirely due to prevention.

    In contrast, the big issues with life expectancy in old age, which have become much more relevant in the last few decades, involve expensive drugs, heart surgery, and cancer. Prevention is important for those as well, but less; I can dig up a study referenced by the American Lung Association that says air pollution cuts 4 months from life expectancy in Europe. It’s a lot in absolute terms, but it’s not 25 years.

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