Cuando un gigante cae, los enanos nos quedamos sin sombra



25 junio 2011 — Barbara Stanfield

Tributo a Barbara Stanfield de Juan Gérvas y Mercedes Pérez Fernández

CUANDO UN GIGANTE CAE, LOS ENANOS NOS QUEDAMOS SIN SOMBRA

Dicen que en la guerra los ancianos entierran a los jóvenes.

Puesto que es la paz y somos viejos, los jóvenes nos han de enterrar.

Dicen que todos somos buenos después de muertos.

Algunos muertos fueron buenos antes de muertos. Buenos, generosos y honrados, sabios y cercanos, realmente humanos.

Algunos muertos nos dieron sombra acogedora y protectora y su caída nos deja a la intemperie, solos ante el peligro.

Hace muchos años nos preguntó uno de nuestros hijos: “cuando muere un viejo sabio, a dónde va su conocimiento y su experiencia”.

No supimos bien qué responder.

“Si tiene familiares y amigos, todos aprendemos unos de otros. Mucho quedará en nuestro corazón y en nuestra mente, y su bondad, su cultura, su sabiduría y sus hechos formarán parte de la memoria que transmitimos de generación en generación, desde que la especie humana empezó a serlo”.

“Si tiene actividad registrada, por escrito o en imágenes, serán sus propias palabras, su propia persona la que podrá ser vista y re~vista, una y otra vez. A veces sin saber quién fue, como el autor anónimo del poema de Gilgamesh. Otras sabiendo quien fue, pero ya con la pátina del olvido, como Aristóteles. Otras con viveza, por la cercanía, como la obra de Albert Einstein”.

No pensamos entonces, pero pensamos ahora, que nos quedamos sin sombra cuando muere un gigante.

Ha muerto Bárbara Starfield, una gigante de la Atención Primaria, y su sombra protectora nos ha abandonado. Era una mujer sabia y anciana, aunque parecía joven y estudiante.

Bárbara Starfield tuvo amigos y familiares capaces de pasar a generaciones futuras su tesoro de conocimiento, bondad, cultura y sabiduría, incluso muchos de sus hechos y anécdotas.

Bárbara Starfield deja registros múltiples, en artículos, libros y presentaciones, que servirán de puente para que otros lleguen más allá.

Bárbara Starfield fue buena antes de muerta.

Ahora es el tiempo de los homenajes, de los panegíricos y epitafios, de los obituarios laudatorios, del recuerdo público en que se mezcla el miedo a la muerte de quien escribe, su propia exhibición y el ansia de olvido de los errores cometidos y de los daños provocados a quien tanto se alaba.

Ahora es el tiempo del culto a la muerte y a los muertos.

Hubo un tiempo para amar, para querer, para la amistad, para compartir, para el respeto amable, pero muchas veces no hubo tiempo, y ya es tarde para dar marcha atrás, ya es tarde para reparar daños y errores.

“Hasta el infinito y más allá”, como dicen los nietos al columpiarlos y al pedir que los abuelos empujemos con más fuerza.

“Hasta el infinito y más allá”.

Llegarán otros más allá, pasarán años y décadas, y siglos y milenios, y la pátina del tiempo nublará el recuerdo de una gigante cuya sombra ha dejado de proteger a los enanos (entre los que nos encontramos).

Ahora somos conscientes de cuán enanos éramos, expuestos al ambiente abrasador de una Medicina arrogante, que desprecia cuanto ignora, e ignora casi todo.

Ahora somos conscientes de que hicimos mucho daño, de que conseguir una visa fue un inconveniente constante para Bárbara Starfield en sus viajes a Brasil. ¡Con lo merecido y fácil que hubiera sido nombrarla ciudadana brasileña de honor!

Ahora somos conscientes de que hicimos daño, mucho daño, cuando en Zaragoza (España) se le negó formar parte de un tribunal universitario de tesis doctoral por no ser doctora en Medicina. ¡Con lo merecido y fácil que hubiera sido nombrarle doctor honoris causa!

Ahora somos conscientes de su escaso impacto en la política sanitaria de los EEUU, su patria. No hay santo que haga milagros en casa, ni gigante que dé sombra a sus los convecinos. ¡Con lo fácil que hubiera sido seguir sus recomendaciones en la política sanitaria, para lograr una Atención Primaria fuerte en un país que la necesita más que ninguno entre los desarrollados!

Fue Bárbara Starfield mujer de izquierdas. Fue siempre sensible al sufrimiento ajeno, activista contra la injusticia.

Conoció a su futuro esposo, también estudiante de Medicina, en un acto a favor de los veteranos de la Brigada Lincoln, una de las Brigadas Internacionales que apoyaron a la República Española contra la barbarie nazi.

Fue pediatra de formación, internacionalista de acción. Se inició en la investigación de la organización de servicios con KL White, maestro y amigo, el de “la ecología de la atención médica”, el de “más vale acertar por aproximación que equivocarse con precisión”. Este gigante le acompañó en los EEUU, como le acompañaron en el Reino Unido gigantes dispares, desde John Fry a Julian Tudor Hart.

Tuvo una actitud crítica positiva, señaló los errores de una atención sanitaria basada en especialistas, y demostró sus peligros (a destacar su texto sobre la actividad médica como causa de muerte evitable), pero al tiempo desarrolló un aparato teórico impresionante de defensa de la Atención Primaria como mejor respuesta a los excesos de la Medicina y de la prevención.

Supo analizar los excesos de la incorrecta aplicación de la metodología estadística, y lo resumió en su artículo sobre “elegancia interna, irrelevancia externa”.

Supo comparar países, supo abrir caminos, supo dar respuestas a los cambios tecnológicos y sociales. Nunca olvidó el impacto de la desigualdad en la salud.

Muchos son los que citan su nombre en vano. Muchos los que justifican barbaridades en nombre de Bárbara Starfield. Muchos los que confunden Atención Primaria con soluciones exclusivas para pobres, de pobre calidad y de programas verticales. Da vértigo pensar en la manipulación de sus ideas por quienes carecen de ellas.

Ya no cabe el recurso a escribir cosas juntos para señalar caminos nuevos, para reivindicar su trabajo y trayectoria.

Ahora queda su recuerdo, el consuelo del rezo en alguna sinagoga, el seguir la senda que abrió, “hasta el infinito y más allá”.

“Hasta el infinito y más allá”.

Juan Gérvas y Mercedes Pérez Fernández

Brasilia, Brasil, Junio de 2011

jgervasc@meditex.es mpf1945@gmail.com

PARA CITAR: Gérvas J, Peréz Fernández M. Quando um gigante cai, os añoes ficam sem sombra. Rev Bras Med Fam Comunidade. 2011 [in press]

Via: Primum Non Nocere – Rafa Bravo.

In Memorian: JH´s Dean for Barbara Starfield


Johns Hopkins Bloomberg School of Public HealthImage via WikipediaMessage from the Dean

Johns Hopkins Bloomberg School of Public Health

Dear colleagues,

I have very sad news. Barbara Starfield, professor of Health Policy and Management, died Friday evening of an apparent heart attack while swimming-an activity that she dearly loved.

Our School has lost one of its great leaders. Barbara was a giant in the field of primary care and health policy who mentored many of us. Her work led to the development of important methodological tools for assessing diagnosed morbidity burden and had worldwide impact. She was steadfast in her belief that a quality primary care system is critical to the future of health care in this country and worldwide and received numerous accolades for her work in this important area.

Barbara came to Johns Hopkins in 1959 as a fellow in pediatrics at the School of Medicine. She joined our School in 1962 where she earned her MPH in epidemiology. As professor, she went on to lead the Division of Health Policy in the Department of Health Policy and Management from 1975 to 1994. After stepping down as Division head, Barbara remained an active member of the HPM faculty and was founding director of the Primary Care Policy Center. She was named Distinguished University Professor in 1994. Barbara was greatly admired as a teacher, mentor and colleague.

I am sure that I speak for all of us when I say that my deepest sympathies are with Tony Holtzman–Barbara’s husband, her four children, her eight grandchildren, as well her many friends and colleagues around the world.

We’ll provide information about funeral arrangements and a memorial service when they are available.

Michael J. Klag, MD, MPH

Dean

Johns Hopkins Bloomberg School of Public Health

Web links:

http://es.wikipedia.org/wiki/Barbara_Starfield

http://www.jhsph.edu/faculty/directory/profile/4169/Starfield/Barbara

http://www.biomedcentral.com/info/publishingservices/profiles/100111

http://www.iseqh.org/

http://www.mgfamiliar.net/Starfield_statement.pdf

In Memorian: Barbara Starfield


Con profunda tristeza los médicos generales y de familia recibimos la noticia del fallecimiento de Barbara Starfield. Comprometida con la atención primaria, las palabras huelgan y copio aqui, para quienes no la conocieron, su pagina de profesora en John Hopkins, la misma Universidad donde nació el modelo flexneriano y que ella combatió. Tuve el honor de, si bien no conocerla personalmente, leerla en la lista de “Social Determinats of Health”, e intercambiar opiniones a través de e-mails. Hemos perdido a un simbolo de la Atención Primaria, pero su pensamiento seguirá vivo. Mi condolencia también a su amigo, quien me dió la noticia, Juan Gervas.

Barbara Starfield

Professor

Academic Degrees
MDMPH
Departmental Affiliation
Name:
Health Policy and Management
Affiliation Type:
Primary
Division:
Primary Care Policy Center
Name:
Population, Family and Reproductive Health
Affiliation Type:
Joint
Departmental Address
452 Hampton House
Contact Information
Email:
bstarfie+jhsph.edu
Phone:
410-955-3737
Fax:
410-614-9046
Link:
Personal Website
Research and Professional Experience
Determinants of health and equity in health; effectivenss and equity of health services; assessment of population health; co-morbidity and case mix; primary care and specialty care and their interrelationships; continuity (longitudinality) of care and its effects; comprehensiveness and coordination of care

Honors and Awards
David Luckman Memorial Award, State University of New York, Downstate Medical Center, 1958. The 1967 Award of The Enuresis Foundation for “significant contribution to knowledge and understanding of enuresis.” Research Scientist Development Award (K02 HS 46225) from the National Center for Health Services Research and Development, 1970-75. Member, Institute of Medicine, National Academy of Sciences. Elected 1977. The George Armstrong Award for Work in Advancing the Goals of Improved Patient Care, Teaching, and Research in Ambulatory Pediatrics. The Ambulatory Pediatric Association, May 1983. First Annual Research Award for Contributions to Research in Child Health. The Ambulatory Pediatric Association, May 1990. Residential Scholar, Bellagio Study Center, Rockefeller Foundation, June 9 – July 13, 1990. Special Recognition Award for the Secretary for Health and Human Services (Task Force to Develop Child Health Indicators, 1990), May 1991. First National Primary Care Achievement Award, Pew Charitable Trusts/Health Resources and Services Administration (DHHS), 1994. Distinguished Investigator Award, Association for Health Services Research, 1995. American Public Health Association‘s Martha May Eliot Award, 1995. AHSR (Association for Health Services Research) Distinguished Fellow, 1996. Maurice Wood Award for Lifetime Contribution to Primary Care Research, North American Primary Care Research Group (NAPCRG), 2000. Honorary Fellow, Royal College of General Practitioners (UK), 2000. Lifetime Achievement Award, Ambulatory Pediatric Association, 2002. Morehouse School of Medicine Excellence in Primary Care Award, 2002

Selected Publications
Gervas J, Starfield B, Heath I. Is clinical prevention better than cure? Lancet 2008; 372:1997-9. Starfield B. Refocusing the system. N Engl J Med 2008; 359(20): 2087, 2091. Lee TH, Bodenheimer T, Goroll AH, Starfield B, Treadway K. Perspective roundtable: redesigning primary care. N Engl J Med 2008; 359(20): e24. Starfield B. Commentary: Access, primary care, and the medical home: rights of passage. Med Care 2008; 46: 1015-16. Starfield B. The biggest bang for the buck: a conversation with Barbara Starfield, M.D., M.P.H. Interview by Sallie Rixey. Md Med 2008; 9(3): 11-3. Rawaf S; De Maeseneer J; Starfield B. From Alma-Ata to Almaty: a new start for primary health care. Lancet 2008; 372(9647): 1365-7. Starfield B. An evidence base for primary care. Managed Care 2008; 17(6): 33-26, 39. Starfield B, Hyde J, Gérvas J, Heath I. The concept of prevention: a good idea gone astray? J Epidemiol Community Health 2008; 62: 580-83. Alonso J, Urzola D, Serra-Sutton V, Tebe C, Starfield B, Riley AW, Rajmil L. Validity of the health profile-types of the Spanish Child Health and Illness Profile – Adolescent Edition (CHIP-AE). Value in Health 2008; 11: 440-9. Starfield B. Editorial: The importance of primary care in health systems. Hong Kong Practitioner 2008; 30: 1-2. Starfield B. Comment: Quality and outcomes framework: patient-centred. Lancet 2008; 372: 692-4. Starfield B. Commentary: Primary care in Canada: coming or going? Healthc Pap 2008; 8: 58-62; discussion 64-7. Starfield B. Social gradients and child health. In Heggenhougen HK, Quah SR (eds.). International Encyclopedia of Public Health, Vol 6, pp. 87-101. San Diego, CA: Academic Press, 2008. Gervas J, Starfield B, Violan C, Minue S. GPs with special interests: unanswered questions. Br J Gen Pract 2007; 57: 912-7. Starfield B, Fryer GE Jr. The primary care workforce: ethical and policy implications. Ann Fam Med 2007; 5: 486-91. Starfield B, Birn A-E. Income redistribution is not enough: income inequality, social welfare programs, and achieving equity in health. J Epidemiol Community Health 2007; 61: 1038-41. Starfield B. Global health, equity, and primary care. J Am Board Fam Med 2007; 20(6): 511-3. Gérvas J, Starfield B, Minué S, Violan C, Seminario de Innovacion en Atencion Primaria 2007. [Some Causes (and Solutions) of the Loss of Prestige of General Practitioners/Family Doctors. Against the Discrediting of Heroes.]. Aten Primaria 2007; 39(11): 615-8. Beasley JW, Starfield B, vanWeel C, Rosser WW, Haq CL. Global health and primary care research. J Am Board Fam Med 2007; 20(6):518-26. Pueyo M-J, Serra-Sutton V, Alonso J, Starfield B, Rajmil L. Self-reported social class in adolescents: validity and relationship with gradients in self-reported health. BMC Health Services Research 2007; 7:151. Pasarin MI, Berra S, Rajmil L, Solans M, Borrell C, Starfield B. [An instrument to evaluate primary health care from the population perspective]. Aten Primaria 2007; 39 (8): 395-401. Forrest CB, Shadmi E, Nutting PA, Starfield B. Specialty referral completion among primary care patients: results from the ASPN Referral Study. Ann Fam Med 2007; 5: 361-7. Starfield B, Horder J. Interpersonal continuity: old and new perspectives. Br J Gen Pract 2007; 57 (540): 527-9. Starfield B. Pathways of influence on equity in health. Soc Sci Med 2007; 64 (7): 1355-62. Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv 2007; 37(1): 111-26. Starfield B, Gervas J. Family medicine should encourage its clinicians to specialize: negative position. Chapter 10 in Buetow SA and Kenealy TW. Ideological Debates in Family Medicine, pp. 107-119. New York, NY: Nova Science Publishers, 2007. Starfield B, Shi L. Commentary: Primary care and health outcomes: a health services research challenge. Health Serv Res 2007; 42(6 Pt 1): 2252-6. Valderas JM, Starfield B, Salisbury C. Definitions of chronic health conditions in childhood. JAMA 2007; 298: 1636. Valderas JM, Starfield B, Roland M. Multimorbidity’s many challenges: A research priority in the UK. BMJ 2007; 334(7604): 1128. Starfield B, Shi L. Commentary: The impact of primary care and what states can do. North Carolina Medical Journal 2007; 68: 204-7. Starfield B. Editorial: Co-morbidity and its challenges for quality of primary care. Rev Port Clin Geral 2007; 23:179-80. Starfield B. Pathways of influence on equity in health: A rejoinder to Braveman and Wilkinson. Soc Sci Med 2007; 64(7): 1371-2.

Prevencion


Dos excelentes articulos de Juan Gervas y Barbara Starfield sobre prevencion. Sin duda y como es de esperar, polemicos como siempre. Espero los disfruten:

Two amazing papers by Juan Gervas (Spain) and Barbara Starfield (USA) about prevention. Without doubt, as we ever expect from them, a good issue to argue the pro and cons. I hope you enjoy them as I did. Thanks Juan, Thanks Barbara. 


prevention_concept_JECH_2008.pdf


prevention_Lancet_2008_publ.pdf

prevention J.Gervas , B.Starfield
prevention J.Gerva…
Hosted by eSnips
prevencion-Gervas Starfield
prevencion-Gervas …
Hosted by eSnips

Prevencion


Dos excelentes articulos de Juan Gervas y Barbara Starfield sobre prevencion. Sin duda y como es de esperar, polemicos como siempre. Espero los disfruten:

Two amazing papers by Juan Gervas (Spain) and Barbara Starfield (USA) about prevention. Without doubt, as we ever expect from them, a good issue to argue the pro and cons. I hope you enjoy them as I did. Thanks Juan, Thanks Barbara. 


prevention_concept_JECH_2008.pdf


prevention_Lancet_2008_publ.pdf

prevention J.Gervas , B.Starfield
prevention J.Gerva…
Hosted by eSnips
prevencion-Gervas Starfield
prevencion-Gervas …
Hosted by eSnips

Crisis en atencion primaria


The editors asked several experts to share their perspectives on the crisis in U.S. primary care. Their articles, which address this crisis from six different angles, follow. We also brought the five U.S. contributors together for a roundtable discussion of the problems and potential solutions for training, practice, compensation, and systemic change. A video of the discussion and reader comments can be seen at http://www.nejm.org.

Primary care has been one of the best jobs in medicine, and it can be again. In fact, primary care must recapture its attraction for the next generation’s best trainees — or the chaos and inefficiency of U.S. health care will only worsen.

The challenges are formidable, for there are so many reasons for young physicians to go into other fields. Many physicians graduate from medical school with staggering debts, and procedure-oriented specialties offer higher potential incomes. The work of primary care is itself overwhelming. Primary care physicians often go home worried that they may have made mistakes, or dispirited because they did not complete their work.

But as Treadway’s story reminds us, failure is not an option. Throughout their lives, but particularly at the end, patients want and need physicians who focus on the people who have diseases, not just the diseases that they have.

Redesigning Primary Care
In a video roundtable discussion moderated by Dr. Thomas Lee, four experts in primary care and related policy explore the crisis, as well as possible solutions for training, practice, compensation, and systemic change.

And when people want and need something, the market usually gives it to them. Right now, patients throughout the UnitedStates are having difficulty finding primary care physicians, so incomes for such practitioners will probably rise as health care organizations struggle to meet the demand for primary care. At the delivery system where I work, we are actively discussingquestions such as how high primary care salaries need to be, where the money to pay them will come from, and how quicklyhigher incomes might work to expand the primary care pipeline.

These questions are difficult to answer, because money is only part of the problem and therefore can be only part of the solution. We have to figure out how to make the job of primary care doable once again. We have to learn how to surround primary care physicians with teams that help them care for their populations of patients, as Bodenheimer argues in his article, and we have to equip them with systems such as electronic medical records to help them manage the flood of information that moves through their offices every day. And, as Goroll suggests in his article, we have to develop payment policies that make these innovations sustainable.

Many organizations have found that when they increase payments to primary care physicians, the physicians respond by reducing the number of patients they see. These physicians, it turns out, place a higher priority on trying to do a good job andhaving a sane life than on making a higher income. The message they’re sending is that more money will not be enough to revitalize primary care.

Revitalization will take something more like reinvention, and it will demand creativity and flexibility from all parties — including primary care physicians themselves. These physicians need to learn to work in teams and adjust to the notion that much of primary care can be delivered by nonphysician team members, some of whom are located in nontraditional settings, such aslimited-service clinics in retail stores.

In this collection of articles, Starfield describes some of the major policy issues that must be addressed as the U.S. health care system develops a stronger primary care focus, and Roland suggests that there are some features of primary care in the United Kingdom that might warrant adaptation. As we test new concepts in the years ahead, primary care will undoubtedly changedramatically. But if we are successful and wise, these changes should allow key aspects of being a primary care physician toremain the same.

Primary care doctors should once again feel a deep sense of satisfaction when they leave their offices or patients’ homes after helping people through difficult times. They should be able to leave work thinking not of their income, or of unanswered phone calls, or of test results that they might have overlooked. They should go home thinking, “This is what I was meant to do.”

No potential conflict of interest relevant to this article was reported.


Source Information

Dr. Lee is network president at Partners HealthCare System, Boston, and an associate editor of the Journal.

Crisis en atencion primaria


The editors asked several experts to share their perspectives on the crisis in U.S. primary care. Their articles, which address this crisis from six different angles, follow. We also brought the five U.S. contributors together for a roundtable discussion of the problems and potential solutions for training, practice, compensation, and systemic change. A video of the discussion and reader comments can be seen at http://www.nejm.org.

Primary care has been one of the best jobs in medicine, and it can be again. In fact, primary care must recapture its attraction for the next generation’s best trainees — or the chaos and inefficiency of U.S. health care will only worsen.
The challenges are formidable, for there are so many reasons for young physicians to go into other fields. Many physicians graduate from medical school with staggering debts, and procedure-oriented specialties offer higher potential incomes. The work of primary care is itself overwhelming. Primary care physicians often go home worried that they may have made mistakes, or dispirited because they did not complete their work.
But as Treadway’s story reminds us, failure is not an option. Throughout their lives, but particularly at the end, patients want and need physicians who focus on the people who have diseases, not just the diseases that they have.

Redesigning Primary Care
In a video roundtable discussion moderated by Dr. Thomas Lee, four experts in primary care and related policy explore the crisis, as well as possible solutions for training, practice, compensation, and systemic change.

And when people want and need something, the market usually gives it to them. Right now, patients throughout the UnitedStates are having difficulty finding primary care physicians, so incomes for such practitioners will probably rise as health care organizations struggle to meet the demand for primary care. At the delivery system where I work, we are actively discussingquestions such as how high primary care salaries need to be, where the money to pay them will come from, and how quicklyhigher incomes might work to expand the primary care pipeline.
These questions are difficult to answer, because money is only part of the problem and therefore can be only part of the solution. We have to figure out how to make the job of primary care doable once again. We have to learn how to surround primary care physicians with teams that help them care for their populations of patients, as Bodenheimer argues in his article, and we have to equip them with systems such as electronic medical records to help them manage the flood of information that moves through their offices every day. And, as Goroll suggests in his article, we have to develop payment policies that make these innovations sustainable.
Many organizations have found that when they increase payments to primary care physicians, the physicians respond by reducing the number of patients they see. These physicians, it turns out, place a higher priority on trying to do a good job andhaving a sane life than on making a higher income. The message they’re sending is that more money will not be enough to revitalize primary care.
Revitalization will take something more like reinvention, and it will demand creativity and flexibility from all parties — including primary care physicians themselves. These physicians need to learn to work in teams and adjust to the notion that much of primary care can be delivered by nonphysician team members, some of whom are located in nontraditional settings, such aslimited-service clinics in retail stores.
In this collection of articles, Starfield describes some of the major policy issues that must be addressed as the U.S. health care system develops a stronger primary care focus, and Roland suggests that there are some features of primary care in the United Kingdom that might warrant adaptation. As we test new concepts in the years ahead, primary care will undoubtedly changedramatically. But if we are successful and wise, these changes should allow key aspects of being a primary care physician toremain the same.
Primary care doctors should once again feel a deep sense of satisfaction when they leave their offices or patients’ homes after helping people through difficult times. They should be able to leave work thinking not of their income, or of unanswered phone calls, or of test results that they might have overlooked. They should go home thinking, “This is what I was meant to do.”
No potential conflict of interest relevant to this article was reported.

Source Information
Dr. Lee is network president at Partners HealthCare System, Boston, and an associate editor of the Journal.

El concepto de prevencion


The concept of prevention: a good idea gone astray?

B Starfield1, J Hyde2,3, J Gérvas4,5, I Heath6

1 Johns Hopkins University, Baltimore, MD, USA
2 Victoria Department of Human Services, Melbourne, Australia
3 Monash University, Melbourne, Australia
4 Equipo CESCA, Madrid, Spain
5 Canencia de la Sierra (Madrid), Spain
6 Caversham Group Practice, London, UK

Correspondence to:
Dr B Starfield, Professor of Health Policy, 624 N Broadway, room 452, Johns Hopkins University, Baltimore, MD 21205-1990, USA; bstarfie@jhsph.edu

Over time, the definition of prevention has expanded so that its meaning in the context of health services is now unclear. As risk factors are increasingly considered to be the equivalent of “diseases” for purposes of intervention, the concept of prevention has lost all practical meaning. This paper reviews the inconsistencies in its utility, and suggests principles that it should follow in the future: a population orientation with explicit consideration of attributable risk, the setting of priorities based on reduction in illness and avoidance of adverse effects, and the imperative to reduce inequities in health.

Texto completo en PDF

El concepto de prevencion


The concept of prevention: a good idea gone astray?

B Starfield1, J Hyde2,3, J Gérvas4,5, I Heath6

1 Johns Hopkins University, Baltimore, MD, USA
2 Victoria Department of Human Services, Melbourne, Australia
3 Monash University, Melbourne, Australia
4 Equipo CESCA, Madrid, Spain
5 Canencia de la Sierra (Madrid), Spain
6 Caversham Group Practice, London, UK

Correspondence to:
Dr B Starfield, Professor of Health Policy, 624 N Broadway, room 452, Johns Hopkins University, Baltimore, MD 21205-1990, USA; bstarfie@jhsph.edu

Over time, the definition of prevention has expanded so that its meaning in the context of health services is now unclear. As risk factors are increasingly considered to be the equivalent of “diseases” for purposes of intervention, the concept of prevention has lost all practical meaning. This paper reviews the inconsistencies in its utility, and suggests principles that it should follow in the future: a population orientation with explicit consideration of attributable risk, the setting of priorities based on reduction in illness and avoidance of adverse effects, and the imperative to reduce inequities in health.

Texto completo en PDF

El concepto de prevencion


Otro excelente articulo de Juan Gervas y Barbara Starfield….. el texto completo fue provisto por Ana Carolina Diaz Oliveira. 

Over time, the definition of prevention has expanded so that its meaning in the context of health services is now unclear. As risk factors are increasingly considered to be the equivalent of “diseases” for purposes of intervention, the concept of prevention has lost all practical meaning. This paper reviews the inconsistencies in its utility, and suggests principles that it should follow in the future: a population orientation with explicit consideration of attributable risk, the setting of priorities based on reduction in illness and avoidance of adverse effects, and the imperative to reduce inequities in health.

The scope of prevention has changed over time. A 1967 textbook stated: “Prevention, in a narrow sense, means averting the development of a pathological state. In a broader sense, it includes all measures—definitive therapy among them—that limit the progression of disease at any stage of its course”.1 A distinction was made between interventions that avert the occurrence of disease (primary prevention) and interventions that halt or slow the progression of a disease or its sequelae at any point after its inception (secondary prevention).

By 1978, the distinctions between types of prevention had expanded to include primary prevention to promote health prior to the development of disease or injuries; secondary prevention to detect disease in early (asymptomatic) stages; and tertiary prevention to reverse, arrest or delay progression of disease.2

Neither the 1967 nor the 1978 definitions used the terminology of “risk factor”, but in 1998, the World Health Organization, in addressing “disease” prevention, stated that it “covers measures not only to prevent the occurrence of disease, such as risk factor reduction, but also to arrest its progress and reduce its consequences once established”. The Australian National Public Health Partnership designated prevention as “action to reduce or eliminate or reduce the onset, causes, complications, or recurrence of disease”.3 Several levels were defined: primordial prevention (“preventing the emergence of predisposing social and environmental conditions that can lead to causation of disease;primary prevention; secondary prevention; and tertiary prevention to improve function, minimise impact, and delay complications”).

The Dictionary of Public Health defined prevention similarly, but conceded that the distinction between levels “is more artificial than real”.4

A recent addition to the lexicon of prevention is “quaternary prevention”. The world organisation of family physicians (WONCA) defined quaternary prevention as “an action taken to identify a patient at risk of over-medicalization, to protect him (sic) from new medical invasion, and to suggest to him (sic) interventions which are ethically acceptable”.5 Gofrit et al. defined quaternary prevention as “debriefing, quality assurance, and improvement processes”, which “complete the cycle of prevention by collecting information about the processes, multi-disciplinary analysis of the data, deriving conclusions, and distributing them to all the involved bodies”.6

Quaternary prevention has also been defined by cardiovascular disease experts as “rehabilitation or restoration of function”, applicable to “those with severe cardiovascular dysfuntion”.7 These three definitions are not easily compatible.

Identification of “risk factors” as part of prevention has been designated a new era in public health and clinical medicine8 and as a new professional activity of epidemiologists.9 10 Risk factors, such as elevated blood pressure, are now even considered as “diseases”.11

The shift from public health to clinical disease is evident in the historical development of the concept of prevention. Geoffrey Rose provided the basis for a population orientation to reducing risk factors associated with coronary heart disease, arguing that only a small proportion of cardiovascular events occur in individuals with high risk scores. He maintained that population-based prevention must be low cost, minimally invasive and avoid discomfort and pain. His arguments have been used in ways never intended: to justify treatment of individuals in clinical settings.12 This reflects the emergence of the concept of “preventive medicine”, particularly in the US. Clinical medicine, while increasingly adopting prevention as a field of activity, lacks a definition of prevention: the Guide to Clinical Preventive Services (US Task Force on Prevention) does not offer one despite increasing confusion about the boundaries between the different levels of prevention. The World Health Organization did not include the term “prevention” as a function of health systems, which are defined as “all the activities whose primary purpose is to promote, restore, and maintain health”.13

Is the concept of “prevention”, with its increasing focus on particular diseases and risk factors (rather than on ill health in general), still useful? When so many people lack adequate access to medical care for their manifest health needs, is it justifiable that routine disease check-up visits are approaching half of all medical visits, as in the United States?1416 Is intervention with four drugs, lifestyle advice and cardiacrehabilitation really prevention, as suggested by the title of a published study “Secondary prevention for patients after a myocardial infarction: summary of NICE guidelines”?17 Is intervention to reduce the blood level of a known “risk factor” (eg homocysteine) really prevention when it does not reduce the occurrence of the disease or improve overall health?18 Should controlling risk factors replace the conventional focus on controlling disease, even if it does not necessarily improve health? Should medication (eg cerivastatin) to improve surrogate outcomes in cardiovascular trials19 20 be considered “prevention” when its use is associated with fatal rhabdomyolisis causing it to be withdrawn from theworld market?21 Is it time for a new formulation?

As a result of marked changes in the organsation of health services and increases in knowledge about the genesis and management of disease, there is good reason to question the differentiation of prevention from other aspects of health care.

Clinical settings are increasingly moving towards population-based medicine. As clinical practices become larger, with defined populations, the realities of individual-based medical care now have to confront the principles of population-based care. Increased risk of an event based upon the presence of a “predisposing factor” with high relative risk may no longer be the main criterion for intervention. The “event” may be too uncommon in the population and hence not practical as a priority. Alternatively, the intervention to reduce excess risk, while useful based on statistical associations in clinical trials, may not be useful in other population groups not included in the trial.22 A prime example is the utility of statins for “prevention” of recurrent myocardial infarct in men and the absence of evidence for their utility in either primary or secondary prevention in women.23 The presence of sex differences in screening for abdominal aortic aneurysm provides another example; screening might be useful in at least some men but is not useful in women.24 Clinical trials might not identify population group differences as most, by virtue of their design, are unable to examine the range of individual and community characteristics that could influence responsiveness to interventions.

A preventive activity might be justified in one setting but not in another just because of differences in prevalence, even though the relative risk based on the exposure is the same. What works in one clinical setting may not work in another, even when the relative risk of a characteristic is the same. Population-based studies of the predictive value of exposures consistently find lower likelihood of disease in the presence of a risk factor than do clinically based studies.25 26 As clinical settings are becoming more and more population based, policies regarding the utility of preventive measures are likely to require change.

Perhaps the biggest threat to the concept of prevention, however, is the progressive lowering of thresholds for “predisease”, particularly hypertension, serum cholesterol and blood sugar. With current thresholds, 97% of all US adults aged 50 and over have one or more of these three risk factors, but only 8% of cardiovascular disease will occur in individuals with any combination of them. The United States Preventive Services Task Force (USPSTF) has yet to update its recommendations for people with the changed definition of these conditions.12Encouraged by interests vested in selling more medications for “prevention” and more medical devices for testing, the pressure for increasing “prevention” in clinical care directed at individuals is inexorable—even though it is not well supported by evidence in populations of patients.27

The focus of prevention has always been on “diseases”. As the concept of “disease” is changing over time (with lowering thresholds for designation of “disease”)28 and risk factors are considered equivalent to disease, the boundaries between prevention and cure are becoming increasingly indistinct. Physicians, as a profession, have always had the power to define “diseases” and stages of diseases.29 30 For example, the current definition of heart failure31 includes four stages. Obesity constitutes stage A, even in the absence of symptoms or structural changes in the heart. Stage B also constitutes being “at risk of heart failure”. Only stages C and D constitute evident heart failure.States A and B are preheart failure – a “diagnosis” justifying medication. When drugs are promoted for prevention and the number of patients at risk is very large, the expanded exposure to the drug may lead to important harm.32 The increasing attention to iatrogenic causes of ill health and the resulting addition of “quaternary prevention” also point to the need to explicitly include iatrogenesis as an influence on ill health.

Recommendations for clinical preventive services still focus largely on the results of analyses of relative risk in individuals not necessarily representative of the population or subpopulations.33 Furthermore, recommendations for risk factor screening are made one by one, despite evidence that risk factors are not independent of each other. On average, adult patients in the US in the mid-1990s were estimated to have approximately 12 risk factors requiring approximately 24 preventive services—even before the explosion of the concept of risks.34 A more recent analysis, recognising some of the limitations of estimates of benefit, set several priorities for clinical prevention in the total population based on “preventable burden” and cost-effectiveness; none involved medications other than immunisations.35

The major challenges in setting policy for interventions to reduce illness seem to be:

  1. avoiding the fallacy that risks are independent 
  2. the importance of setting priorities based upon frequency of the desired outcome in populations 
  3. the importance of setting priorities to reduce inequities in health in populations as well as or in preference to improving effectiveness in individuals 
  4. considering when it is more efficient (and perhaps more effective and equitable) to prioritise interventions to populations, includingdefined populations in the clinical sector 
  5. placing priority on improving health generically (as, for example, by reduction in overall and age-specific death rates, by improvementsin life expectancy and by reductions in disability and in perceived poor health) rather than disease by disease33 36 37 
  6. taking into account the patient’s perspective in clinical prevention38 
  7. avoiding incentives for physician activities that are measurable but of low priority for population health gain.39 

A framework (table 1) for conceptualising reductions in the occurrence and severity and progression of disease would both abandon the confusing and outmoded approach to prevention and substitute a framework that distinguishes societal from individual interventions on the one hand and, on the other, distinguishes risks that result from suboptimal physical, social, health service and individual environments.

View this table:
[in this window]
[in a new window]

 

Table 1 Levels and types of interventions to improve health*

 
The increasing world focus on achieving equity in health40 is likely to bring greater pressure on advocates of “prevention” to more clearly delineate the scope of the concept and the nature of ameliorative efforts. If inequities in health are to be reduced or eliminated, the full range of possible interventions needs to be specified and choices made about priorities. The “web” of influences on health and on inequity in health is very broad, ranging from societal influences to policy influences, to community influences, to social relationships and to individual characteristics (innate as well as developmental, biological and behavioural).41 The possibilities for prevention are vast, involving very differenttypes of approaches and constituencies because prevention involves virtually every sector of societal, social and individual endeavour.

It would be presumptuous to suggest that the term “prevention”, which is so widely entrenched in medical thinking and supported by committed constituencies, could be discarded even if its vagueness is largely dysfunctional. It may be possible, however, to seek agreement on two critical aspects: a focus on population health and a focus on reducing disparities (inequities) in health.

“Population based” is no longer synonymous with “public health”. Public health constitutes societal approaches to improving health, but “population based” means that evidence is derived from population statistics rather than from individual patients in unrepresentative clinical practice. Priorities for action are made on the basis of population-based evidence, which includes consideration of attributable risk as well as relative risk. The hazards of clinical prevention have been catalogued42 and include such considerations as absence of evidence relevant to setting priorities and imprecision of rules allowing prediction of benefit; competition of clinical preventive activities with care of manifest problems; and compromised health resulting from preventive interventions. In view of the systematic dismantling of the public health infrastructure in at least some countries with concomitant increases in the scope and influence of clinical services, an adoption of populationprinciples for clinical services would appear to be in order.

A fresh approach to prevention requires a refocusing of attention from evidence relevant to individuals to evidence relevant to populations—even those in clinical settings. Preventive activities have widely differing effectiveness; in choosing preventive activities, impact on populations and especially on the distribution of health (ie equity in health) within populations should take precedence. The distinction between population and clinical bases for health policy decisions is made clear by the following example. Individual risk factors for tuberculosis in Russia in order of degree of risk are: low household wealth; incarceration in prison or detention; drug misuse; financial insecurity; unemployed; overcrowded living; living with a person with tuberculosis; and heavy drinking. Population risk factors are different. The two major risks in the population are unemployment and consumption of raw milk.43 Policy decisions should be targeted primarily at risks that are common in the population, not atthe extent of increased risk in individuals.

The lagging performance of the US on virtually every health indicator may be testimony to the high-profile but inadvisable concentration on interventions based on managing risks in individual patients. In the same way, reductions in inequities in health are likely to be intractable in countries where the focus of attention is on the receipt of “indicated care” in largely affluent populations who have access to care. The success of prevention is ultimately measured in population health measures and, increasingly, on reducing avoidable differences in health across population subgroups, rather than on meeting professional criteria for “quality of care”.

In its focus primarily on professionally defined disease entities, the practice of medicine (and particularly the practice of “prevention”) is moving increasingly further from its roots in the care of patients—true “patient-centred care”.29 In view of the large extent of coexistence of diseases (multimorbidity) in individuals and in subpopulations, the increasing rates of adverse events that have no representation in disease statistics, the variability in impact on functioning even within diseases and the disability and dysfunction in the absence of conventional disease labels, there is an urgent need for measures of health that cut across diseases and disease categories (http://www.acg.jhsph.edu). Generic measures based on impact can also be used to good advantage; examples are death rates, disability rates, years of potential life lost, low birthweight and measures such as health-adjusted life expectancy and disability-adjusted life expectancy.

The major challenge is to set priorities based on likely improvements in overall (not disease-specific) health in populations and population subgroups, by conceptualising prevention as a set of activities. The ambitious US-led Goals for the Nation lacked focus on activities driven by the need to improve health more broadly than its current focus on specific diseases. The more recent activities-directed quality objectives (with consequent payment for performance) are activities without health or equity in health goals. The need to ensure better health for populations(especially in developing countries) and better distribution of health (in all countries) demands a refocus on health rather than on preventing specific diseases.

As policy decisions about prevention and care often compete with decisions made on the basis of equity, calculation of the costs and benefits of various preventive strategies should be done both ways, including a cost–consequences approach, in order to make explicit the nature of decisions that societies must make.44


El concepto de prevencion


Otro excelente articulo de Juan Gervas y Barbara Starfield….. el texto completo fue provisto por Ana Carolina Diaz Oliveira. 

Over time, the definition of prevention has expanded so that its meaning in the context of health services is now unclear. As risk factors are increasingly considered to be the equivalent of “diseases” for purposes of intervention, the concept of prevention has lost all practical meaning. This paper reviews the inconsistencies in its utility, and suggests principles that it should follow in the future: a population orientation with explicit consideration of attributable risk, the setting of priorities based on reduction in illness and avoidance of adverse effects, and the imperative to reduce inequities in health.

The scope of prevention has changed over time. A 1967 textbook stated: “Prevention, in a narrow sense, means averting the development of a pathological state. In a broader sense, it includes all measures—definitive therapy among them—that limit the progression of disease at any stage of its course”.1 A distinction was made between interventions that avert the occurrence of disease (primary prevention) and interventions that halt or slow the progression of a disease or its sequelae at any point after its inception (secondary prevention).

By 1978, the distinctions between types of prevention had expanded to include primary prevention to promote health prior to the development of disease or injuries; secondary prevention to detect disease in early (asymptomatic) stages; and tertiary prevention to reverse, arrest or delay progression of disease.2

Neither the 1967 nor the 1978 definitions used the terminology of “risk factor”, but in 1998, the World Health Organization, in addressing “disease” prevention, stated that it “covers measures not only to prevent the occurrence of disease, such as risk factor reduction, but also to arrest its progress and reduce its consequences once established”. The Australian National Public Health Partnership designated prevention as “action to reduce or eliminate or reduce the onset, causes, complications, or recurrence of disease”.3 Several levels were defined: primordial prevention (“preventing the emergence of predisposing social and environmental conditions that can lead to causation of disease;primary prevention; secondary prevention; and tertiary prevention to improve function, minimise impact, and delay complications”).

The Dictionary of Public Health defined prevention similarly, but conceded that the distinction between levels “is more artificial than real”.4

A recent addition to the lexicon of prevention is “quaternary prevention”. The world organisation of family physicians (WONCA) defined quaternary prevention as “an action taken to identify a patient at risk of over-medicalization, to protect him (sic) from new medical invasion, and to suggest to him (sic) interventions which are ethically acceptable”.5 Gofrit et al. defined quaternary prevention as “debriefing, quality assurance, and improvement processes”, which “complete the cycle of prevention by collecting information about the processes, multi-disciplinary analysis of the data, deriving conclusions, and distributing them to all the involved bodies”.6

Quaternary prevention has also been defined by cardiovascular disease experts as “rehabilitation or restoration of function”, applicable to “those with severe cardiovascular dysfuntion”.7 These three definitions are not easily compatible.

Identification of “risk factors” as part of prevention has been designated a new era in public health and clinical medicine8 and as a new professional activity of epidemiologists.9 10 Risk factors, such as elevated blood pressure, are now even considered as “diseases”.11

The shift from public health to clinical disease is evident in the historical development of the concept of prevention. Geoffrey Rose provided the basis for a population orientation to reducing risk factors associated with coronary heart disease, arguing that only a small proportion of cardiovascular events occur in individuals with high risk scores. He maintained that population-based prevention must be low cost, minimally invasive and avoid discomfort and pain. His arguments have been used in ways never intended: to justify treatment of individuals in clinical settings.12 This reflects the emergence of the concept of “preventive medicine”, particularly in the US. Clinical medicine, while increasingly adopting prevention as a field of activity, lacks a definition of prevention: the Guide to Clinical Preventive Services (US Task Force on Prevention) does not offer one despite increasing confusion about the boundaries between the different levels of prevention. The World Health Organization did not include the term “prevention” as a function of health systems, which are defined as “all the activities whose primary purpose is to promote, restore, and maintain health”.13

Is the concept of “prevention”, with its increasing focus on particular diseases and risk factors (rather than on ill health in general), still useful? When so many people lack adequate access to medical care for their manifest health needs, is it justifiable that routine disease check-up visits are approaching half of all medical visits, as in the United States?1416 Is intervention with four drugs, lifestyle advice and cardiacrehabilitation really prevention, as suggested by the title of a published study “Secondary prevention for patients after a myocardial infarction: summary of NICE guidelines”?17 Is intervention to reduce the blood level of a known “risk factor” (eg homocysteine) really prevention when it does not reduce the occurrence of the disease or improve overall health?18 Should controlling risk factors replace the conventional focus on controlling disease, even if it does not necessarily improve health? Should medication (eg cerivastatin) to improve surrogate outcomes in cardiovascular trials19 20 be considered “prevention” when its use is associated with fatal rhabdomyolisis causing it to be withdrawn from theworld market?21 Is it time for a new formulation?

As a result of marked changes in the organsation of health services and increases in knowledge about the genesis and management of disease, there is good reason to question the differentiation of prevention from other aspects of health care.

Clinical settings are increasingly moving towards population-based medicine. As clinical practices become larger, with defined populations, the realities of individual-based medical care now have to confront the principles of population-based care. Increased risk of an event based upon the presence of a “predisposing factor” with high relative risk may no longer be the main criterion for intervention. The “event” may be too uncommon in the population and hence not practical as a priority. Alternatively, the intervention to reduce excess risk, while useful based on statistical associations in clinical trials, may not be useful in other population groups not included in the trial.22 A prime example is the utility of statins for “prevention” of recurrent myocardial infarct in men and the absence of evidence for their utility in either primary or secondary prevention in women.23 The presence of sex differences in screening for abdominal aortic aneurysm provides another example; screening might be useful in at least some men but is not useful in women.24 Clinical trials might not identify population group differences as most, by virtue of their design, are unable to examine the range of individual and community characteristics that could influence responsiveness to interventions.

A preventive activity might be justified in one setting but not in another just because of differences in prevalence, even though the relative risk based on the exposure is the same. What works in one clinical setting may not work in another, even when the relative risk of a characteristic is the same. Population-based studies of the predictive value of exposures consistently find lower likelihood of disease in the presence of a risk factor than do clinically based studies.25 26 As clinical settings are becoming more and more population based, policies regarding the utility of preventive measures are likely to require change.

Perhaps the biggest threat to the concept of prevention, however, is the progressive lowering of thresholds for “predisease”, particularly hypertension, serum cholesterol and blood sugar. With current thresholds, 97% of all US adults aged 50 and over have one or more of these three risk factors, but only 8% of cardiovascular disease will occur in individuals with any combination of them. The United States Preventive Services Task Force (USPSTF) has yet to update its recommendations for people with the changed definition of these conditions.12Encouraged by interests vested in selling more medications for “prevention” and more medical devices for testing, the pressure for increasing “prevention” in clinical care directed at individuals is inexorable—even though it is not well supported by evidence in populations of patients.27

The focus of prevention has always been on “diseases”. As the concept of “disease” is changing over time (with lowering thresholds for designation of “disease”)28 and risk factors are considered equivalent to disease, the boundaries between prevention and cure are becoming increasingly indistinct. Physicians, as a profession, have always had the power to define “diseases” and stages of diseases.29 30 For example, the current definition of heart failure31 includes four stages. Obesity constitutes stage A, even in the absence of symptoms or structural changes in the heart. Stage B also constitutes being “at risk of heart failure”. Only stages C and D constitute evident heart failure.States A and B are preheart failure – a “diagnosis” justifying medication. When drugs are promoted for prevention and the number of patients at risk is very large, the expanded exposure to the drug may lead to important harm.32 The increasing attention to iatrogenic causes of ill health and the resulting addition of “quaternary prevention” also point to the need to explicitly include iatrogenesis as an influence on ill health.

Recommendations for clinical preventive services still focus largely on the results of analyses of relative risk in individuals not necessarily representative of the population or subpopulations.33 Furthermore, recommendations for risk factor screening are made one by one, despite evidence that risk factors are not independent of each other. On average, adult patients in the US in the mid-1990s were estimated to have approximately 12 risk factors requiring approximately 24 preventive services—even before the explosion of the concept of risks.34 A more recent analysis, recognising some of the limitations of estimates of benefit, set several priorities for clinical prevention in the total population based on “preventable burden” and cost-effectiveness; none involved medications other than immunisations.35

The major challenges in setting policy for interventions to reduce illness seem to be:

  1. avoiding the fallacy that risks are independent 
  2. the importance of setting priorities based upon frequency of the desired outcome in populations 
  3. the importance of setting priorities to reduce inequities in health in populations as well as or in preference to improving effectiveness in individuals 
  4. considering when it is more efficient (and perhaps more effective and equitable) to prioritise interventions to populations, includingdefined populations in the clinical sector 
  5. placing priority on improving health generically (as, for example, by reduction in overall and age-specific death rates, by improvementsin life expectancy and by reductions in disability and in perceived poor health) rather than disease by disease33 36 37 
  6. taking into account the patient’s perspective in clinical prevention38 
  7. avoiding incentives for physician activities that are measurable but of low priority for population health gain.39 

A framework (table 1) for conceptualising reductions in the occurrence and severity and progression of disease would both abandon the confusing and outmoded approach to prevention and substitute a framework that distinguishes societal from individual interventions on the one hand and, on the other, distinguishes risks that result from suboptimal physical, social, health service and individual environments.

View this table:
[in this window]
[in a new window]

 

Table 1 Levels and types of interventions to improve health*

 
The increasing world focus on achieving equity in health40 is likely to bring greater pressure on advocates of “prevention” to more clearly delineate the scope of the concept and the nature of ameliorative efforts. If inequities in health are to be reduced or eliminated, the full range of possible interventions needs to be specified and choices made about priorities. The “web” of influences on health and on inequity in health is very broad, ranging from societal influences to policy influences, to community influences, to social relationships and to individual characteristics (innate as well as developmental, biological and behavioural).41 The possibilities for prevention are vast, involving very differenttypes of approaches and constituencies because prevention involves virtually every sector of societal, social and individual endeavour.

It would be presumptuous to suggest that the term “prevention”, which is so widely entrenched in medical thinking and supported by committed constituencies, could be discarded even if its vagueness is largely dysfunctional. It may be possible, however, to seek agreement on two critical aspects: a focus on population health and a focus on reducing disparities (inequities) in health.

“Population based” is no longer synonymous with “public health”. Public health constitutes societal approaches to improving health, but “population based” means that evidence is derived from population statistics rather than from individual patients in unrepresentative clinical practice. Priorities for action are made on the basis of population-based evidence, which includes consideration of attributable risk as well as relative risk. The hazards of clinical prevention have been catalogued42 and include such considerations as absence of evidence relevant to setting priorities and imprecision of rules allowing prediction of benefit; competition of clinical preventive activities with care of manifest problems; and compromised health resulting from preventive interventions. In view of the systematic dismantling of the public health infrastructure in at least some countries with concomitant increases in the scope and influence of clinical services, an adoption of populationprinciples for clinical services would appear to be in order.

A fresh approach to prevention requires a refocusing of attention from evidence relevant to individuals to evidence relevant to populations—even those in clinical settings. Preventive activities have widely differing effectiveness; in choosing preventive activities, impact on populations and especially on the distribution of health (ie equity in health) within populations should take precedence. The distinction between population and clinical bases for health policy decisions is made clear by the following example. Individual risk factors for tuberculosis in Russia in order of degree of risk are: low household wealth; incarceration in prison or detention; drug misuse; financial insecurity; unemployed; overcrowded living; living with a person with tuberculosis; and heavy drinking. Population risk factors are different. The two major risks in the population are unemployment and consumption of raw milk.43 Policy decisions should be targeted primarily at risks that are common in the population, not atthe extent of increased risk in individuals.

The lagging performance of the US on virtually every health indicator may be testimony to the high-profile but inadvisable concentration on interventions based on managing risks in individual patients. In the same way, reductions in inequities in health are likely to be intractable in countries where the focus of attention is on the receipt of “indicated care” in largely affluent populations who have access to care. The success of prevention is ultimately measured in population health measures and, increasingly, on reducing avoidable differences in health across population subgroups, rather than on meeting professional criteria for “quality of care”.

In its focus primarily on professionally defined disease entities, the practice of medicine (and particularly the practice of “prevention”) is moving increasingly further from its roots in the care of patients—true “patient-centred care”.29 In view of the large extent of coexistence of diseases (multimorbidity) in individuals and in subpopulations, the increasing rates of adverse events that have no representation in disease statistics, the variability in impact on functioning even within diseases and the disability and dysfunction in the absence of conventional disease labels, there is an urgent need for measures of health that cut across diseases and disease categories (http://www.acg.jhsph.edu). Generic measures based on impact can also be used to good advantage; examples are death rates, disability rates, years of potential life lost, low birthweight and measures such as health-adjusted life expectancy and disability-adjusted life expectancy.

The major challenge is to set priorities based on likely improvements in overall (not disease-specific) health in populations and population subgroups, by conceptualising prevention as a set of activities. The ambitious US-led Goals for the Nation lacked focus on activities driven by the need to improve health more broadly than its current focus on specific diseases. The more recent activities-directed quality objectives (with consequent payment for performance) are activities without health or equity in health goals. The need to ensure better health for populations(especially in developing countries) and better distribution of health (in all countries) demands a refocus on health rather than on preventing specific diseases.

As policy decisions about prevention and care often compete with decisions made on the basis of equity, calculation of the costs and benefits of various preventive strategies should be done both ways, including a cost–consequences approach, in order to make explicit the nature of decisions that societies must make.44