Turning over a new leaf in 2015 to prevent debilitating disease

Efforts to prevent disease and to promote good health always are preferred strategies over efforts to treat disease. Yet, we spend far too little time, attention, and effort on either of these strategies. Both remain very underdeveloped in behavioral health. This reality persists despite the fact that both are included in the Essential Health Benefit and the Medicaid Alternative Benefit mandated by the Affordable Care Act (ACA).

We must begin with some basic distinctions. First, health and disease are two different personal states rather than two features of a single state. For this reason, disease prevention and health promotion imply different interventions, even though these interventions may have cross-effects. Second, because health promotion, per se, not only can improve personal health, but also prevent or delay disease onset, it is very important that we engage in both types of interventions at the same time. Ideally, both should be started very early in life. Third, because our current “health care” system is oriented principally toward disease treatment, we will need to make major modifications to our current health care infrastructure in order to incorporate health promotion and disease prevention.

This commentary will focus on disease prevention; a previous related commentary discussed health promotion (see  https://www.behavioral.net/blogs/ron-manderscheid/promoting-good-health).

Like health promotion efforts, our prevention efforts will need to be directed at communities, per se, and at individual community members. Some interventions will address all community members; some, only those at risk of disease; and some, only those who currently have disease. This is the classic approach to prevention.

Prevention at the Community Level

For Everyone. Over the past quarter century, we have learned that many diseases can be traced to issues with our culture, our social institutions, and our communities. Poverty, income disparities, racial discrimination, inadequate education—each a social determinant of one’s health—can play a pivotal role in the etiology of disease and in early mortality. As factors in disease genesis, these determinants function principally through the trauma they induce. Their effects can be seen in the disparities in health status and social exclusion experienced by different groups in the community. Their effects also can be seen in mental and substance use conditions, as well as in other debilitating diseases. Thus, efforts to prevent disease should begin with these community factors.

The only way that the social and physical health determinants can be addressed effectively is at the community level; such interventions are needed to make changes in our culture, our social institutions, and how our communities actually function. For example, these community interventions could include efforts to reduce the effects of poverty on a community and its members (e.g. like the Head Start Program). Or they may be interventions designed to increase the high school graduation rate in a community. Such interventions should be directed at the entire community, because the effects can benefit everyone in that community.

For Those at Risk. Disparities in health status provide very important clues about the subgroups in a community at greater risk of disease. For these subgroups, more targeted community interventions are needed to decrease these disparities and the likelihood of subsequent disease. For example, persons with obesity are at increased risk of a broad range of debilitating diseases. Targeted community interventions are needed to promote the availability of healthy foods in a community, improve opportunities for exercise, and engage in community dialogues on healthy eating habits in order to decrease this health disparity. Similarly, persons who have experienced trauma are at increased risk of mental illness and substance use conditions, and targeted community interventions are needed for these persons.

For Those with Disease. For those in a community who already have one or more diseases, an exceptionally important community action is social inclusion. For example, this action may range from friendly visiting with elders who cannot leave their homes to full outreach and opportunity for participation in work and social groups for those younger adults with serious mental illness or substance use conditions. A second very important related community action is accessibility, not only for health care services, but also for community amenities, such as parks, restaurants, recreation groups, etc. 

The important point about community-level prevention is that it consists of actions taken by a community to benefit all or a subset of community members. The social and physical determinants of health, health disparities, and social exclusion/lack of access are known to be major factors in the onset and severity of mental and substance use conditions.  For this reason, it is essential that behavioral health move quickly to become a public health discipline capable of developing and leading such community interventions designed to prevent or ameliorate disease.

Prevention at the Personal Level

Prevention at the personal level follows the same underlying logic as at the community level. Some interventions are directed at everyone in a community; some, only at those at risk of disease; and some, only at those who already have disease. The essential difference is that, for the most part, these interventions are implemented just one person at a time. Here, I have cited three personal interventions that relate to mental and substance use conditions. Other examples need to be developed and made part of this effort.

For Everyone. Training in resiliency can improve how one responds to and copes with personal difficulty, stress, and trauma. Hence, everyone should receive age appropriate resiliency training.

For Those at Risk. For those at increased risk of a mental or substance use condition, very early identification and intervention can be key to reducing subsequent severity or actually mitigating the disease.

For Those with Disease. For those who already have one or more of these conditions, self-management and wellness strategies can mitigate relapse and severity. As an example of the latter, health activation strategies can be very important personal prevention tools (see https://www.behavioral.net/blogs/ron-manderscheid/recovery-resilience-health-activation).

Next Steps

Both the Affordable Care Act (see overview at    https://www.tandfonline.com/doi/full/10.1080/1536710X.2013.870510#.UwePis7EUs0) and the National Prevention Strategy developed by the US Department of Health and Human Services (see https://www.cdc.gov/features/preventionstrategy/) create energizing opportunities for us to develop, test, and implement community and personal prevention interventions.

The Substance Abuse and Mental Health Services Administration provides essential leadership in developing community and personal prevention interventions for mental health and substance use conditions (see  https://beta.samhsa.gov/programs-campaigns). Recently, Paolo Del Vecchio, the Director of SAMHSA’s Center for Mental Health Services, has written eloquently about the power of prevention (see https://blog.samhsa.gov/2014/05/28/the-power-of-prevention/#.U4iH0zYZ4nI).

The Centers for Disease Control and Prevention also supports a broad range of programs and publications on community and personal prevention interventions that are of considerable interest to our field (see https://www.cdc.gov/chronicdisease/index.htm).

Clearly, additional work at a much accelerated pace is needed to optimize the opportunities created by the Affordable Care Act, so that community and personal prevention interventions are readily available to all Americans.  

What you learned as a young child does ring true: An ounce of prevention is worth a pound of cure.