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 http://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.