Prevention Not Always Better than Cure, Mr Hancock

Health and Social Care Secretary Matt Hancock has jumped aboard the prevention bandwagon, telling the International Association of National Public Health Institutes ‘If there’s one thing that everybody knows it’s: ‘prevention is better than cure’’. Sadly it isn’t. Prevention, like any intervention, can have side effects that outweigh the benefits as his predecessor Jeremy Hunt found. After meetings with drug companies researching dementia, Hunt decided that GPs needed to pick up dementia earlier, to prevent it getting worse, so he offered them £55 per new diagnosis via screening. The trouble is, the screening tests are often wrong.  Take 100 people over 65, and 6 will have dementia. Screening will miss 2 of them. Even worse, 23 will have a false positive result. Only when the press found people were panicking, selling up and moving into care homes when they thought they had dementia, only to find they had mild cognitive impairment, did Hunt and NHS England ditch the bribe (Eye ..).

There are three types of prevention. Primary, which aims to stop a  disease occurring at all (e.g. healthy living, vaccination).  Secondary, which aims to control a disease in an early form  (e.g. carcinoma in situ) and tertiary, which aims to prevent the complications of an established disease (e.g. diabetes). None are perfect and not all diseases are preventable or even fully understood, so Hancock must be wary of falling into the ‘if you get sick, it’s your fault’ trap. However, staring across the aisle at a slim Tom Watson has clearly given him food for thought. Watson lost seven stone in just over a year and reversed his type II diabetes with a better diet and more exercise, so why not everyone?

Watson’s success is partly explained by Sir Michael Marmot, who’s research discovered that power, status and social standing are very strong indicators of health and longevity. If you have a measure of control over your job, your life and your environment, with high self-worth and excellent social connections, you’re far more likely to be healthy. Conversely, if you have no job, no house, no self-esteem, no future an no reason to live, you’re less likely to pop down to Waitrose for a couple of oily fish and a punnet of seasonal berries. In the same borough of Kensington, you lose 22 years of life expectancy and gain 20 years of chronic disease, if you move from Harrods to Grenfell.

Watson discovered that successive governments’ public health strategy for the last 40 years ‘to encourage individuals to make healthy choices’ has also given them the wrong information, allowing the food and pharma industries to run riot. Just as it took 50 years from the discovery that smoking kills you to ban it in public places, we’ve known for 50 years that sugar was the prime driver of obesity but instead blamed saturated fat. Doctors have for decades focused on the aggressive lowering of low-density lipoprotein cholesterol to reduce heart disease risk by cutting out saturated fats in the diet and prescribing statins. This in turn encouraged the food industry to aggressively market zero or low fat foods that claimed to be ‘heart healthy’ but were anything but, being crammed with sugar. This slavish mantra of low fat, low cholesterol and ‘statins for all’ has made billions for food and pharma firms but has helped trigger the massive rise in obesity and type 2 diabetes, where the main culprit is the sugar spikes from processed foods. And the solution is not new drugs, but better food.

Hancock’s latest attempt at ‘encouraging people to make healthy choices’ doesn’t even mention sleep.  60% of adults don’t get their requisite 8 hours a night and there is now clear evidence of the risks of sleep deprivation. The less you sleep, the quicker you die from any combination of depression, anxiety, dementia, stroke, heart disease, obesity, cancer, diabetes, suicide and accidents, especially falling asleep at the wheel. ‘Sleep hygiene’ advice may help, but an estimated 400,000 children don’t have a mattress to sleep on. And if you’re living with debt, depression, drug addiction, domestic abuse or dementia, eight hours sleep a night is a pipe dream. Health is still largely socially determined.

Hancock’s enthusiasm for tech solutions to prevention must be evidence-based. Some people are motivated by having continuous feedback of their pulse, blood pressure, calorie intake and activity levels to a smart watch App, for others it’s hell on earth. There are already too many private screening companies offering expensive tests to work out your risk of future illnesses based on minimal evidence, fueling profits and anxiety in equal measure. Large cuts to public health budgets will not help those less well connected than Tom Watson to rediscover their health. And lengthening waiting times are currently causing widespread preventable suffering to millions. Over to you, Matt.