Downstream Prevention

There is an old metaphorical story about prevention that involves dead bodies in a river.  I first read this story as an MPH student in 1978, somewhere deep in the stacks of journals at the University of Michigan School of Public Health. Having recently emerged from medical care into public health, the metaphor especially struck me.  There was a panic at a riverfront, with an urgent appeal for assistance to retrieve dead bodies from the river.  The person who chose to disengage from that process to head upstream to identify the source of the problem was bitterly criticized for not helping.  Of course, as the story goes, that person found the source of the problem and prevented many deaths.  I have heard many versions of this same metaphor over the past 30 years, sometimes involving other embellishments, including dead babies.  However told, the story always implies that the body retrievers are the health care system and the upstream-headed hero is someone with a more preventive orientation.

Going upstream is important, but in our pursuit of upstream problems we in public health sometimes fail to recognize the value of downstream prevention.  Clearly, if the bodies in the river are already dead, then their retrieval is not an urgent matter.  But as we head upstream, let's occasionally take a look into the river as we go.  If we note that there are many in the river who are still in a process of drowning, we need to jump in.  

The upstream mantras of the day are now "social determinants of health" and "policy".  Factors such as community design, education, and poverty are major determinants of health, and making sure health-supporting policies are in place is important work.  There are many important roles for public health to play in these upstream societal solutions to health problems, but as we move upstream to take on social justice and policy matters, let's be sure to take a look at what is going on in the river.  If people are drowning, someone needs to get wet to help.

The Affordable Care Act defines a new framework for downstream prevention - accountability and reward for partnerships between public health and health care systems to better manage risk factors for chronic diseases. Treating hypertension or hyperlipidemia or tobacco addiction or obesity or finding cancer at earlier stages have become disease treatment enterprises, but they are also prevention.  Those of us in public health will just need to get a little wet to get that done.  We have done a remarkably poor job in controlling these risk factors in the population by the efforts of clinical care alone.  Now, with new mandates and new incentives to do a better job, new partnerships between health care systems and public health systems need to be developed. 

The question we in public health need to ask ourselves is whether establishing systems to better control chronic diseases is a role we want to play, or whether this is only a job for health care providers.  I think there is a public health job to do here. We now need to do two things at once in public health - to effectively move upstream to engage in social solutions in matters of public policy for health and social justice, and also set up lifeguard posts along the river to more effectively enact what we have known for over 30 years will save lives from chronic diseases.  We should be able to do both.