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Rose's Strategy of Preventive Medicine
Rose's Strategy of Preventive Medicine
Rose's Strategy of Preventive Medicine
Preventive Medicine
Ch1-Ch4
Presenter: Ting-Yu Lin
Lecturer: Prof. Wei-Chu Chie
Date: 2017/11/14
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The objectives of
preventive medicine
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The objectives of preventive medicine
• knowledge is sufficient to achieve great health gains
for all and to reduce our scandalous international and
national inequalities in health
Knowledge Action
Impeded by
widespread ignorance
Lack of understanding of the issues
and possibilities
The deliberate opposition of
powerful vested interests
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The scope for prevention
Cervical cancer is twenty times commoner in Colombia than in Israel
10 per cent of Indian children die before their first birthday whereas
in Western countries 99 per cent of babes survive
Virchow, the great German pathologist of the last century, wrote:
Epidemics appear, and often disappear without traces, when a new culture
period has started; thus with leprosy, and the English sweat. The history of
epidemics is therefore the history of disturbances of human culture (Virchow,
in Ackerknecht 1970).
In Western,
Infection heart attack and duodenal ulcer
The scale and pattern of disease reflect the way that people live and
their social, economic, and environmental circumstances, and all of
these can change quickly
Preventable
Can we control our history, or must we only analyse and observe it?
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Why seek to prevent?
‘Take no thought for the morrow … sufficient unto the day is
the evil thereof’ (Matthew, Chapter 6, Verse 34).
Disease
impairs earning capacity
Prevention will be a
the costs of medical care are high money-saver.
Misleading
For example,
The avoidance of cigarettes will greatly reduce the risks at each age of
suffering a heart attack, but as a result non-smokers live longer and so
more of them are exposed to the particularly high risk of heart attack in
old age.
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The economist argument
• the costs of investigation and care have been inversely related to
the changes in incidence! A dynamic relationship between medical
care costs and epidemiologically established needs has proved hard
to establish.
-Widespread decline in the incidence of coronary heart disease led to
any fall in the numbers of cardiologists and cardiac surgeons
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The objectives of preventive
medicine
• Priorities: a matter of choice
-The achievement of better health implies many
kinds of costs which must be paid
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What needs to be
prevented?
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What needs to be prevented?
• High-risk approach
-prevention has tended to concentrate attention on the
conspicuous segment of disease and risk
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• See situations in clear and dichotomous terms
sick vs. healthy
creates indecision and uncertainty
• Pickering(1954)
Hypertension didn’t exist as a distinguishable entity.
Fig. 2.1 Disease and its risk
factors are quantitative not
categorical phenomena: the
distribution of systolic blood
pressure in a population of
middle-aged men.
blood pressure does indeed come in all degrees, with ‘low’ merging
imperceptibly into ‘high’
Was not able to alter medicine’s underlying commitment to the belief
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A continuum of disease severity
• Cancer
• Stroke
none at alltransient ischaemic attacka stroke with persistent
disabilitya dramatic and rapidly fatal illness
• Pregnancy
Merely potential fertilized ovum, implantation in the uterus
biochemically detectable pregnancy clinically evident pregnancy
recognizably human fetus viable fetus live baby
• Senile dementia
‘normality’ merges imperceptibly into ‘dementia’
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Case definitions
• The practical necessity for case definitions is
nevertheless obvious and has always been recognized
- patient is either admitted or allowed home
- a drug is given in full dose or not at all
Illogical situation:
Disease truly forms a continuum of severity, but its management
requires a system of unambiguous labels
Cases of depression vs. cases for antidepressive treatment
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• Doctors: give the highest priority to the prevention of death and
acute illness
• Members of the public: attach more importance to how they feel
and to impairments of daily living
• The two outlooks imply different views of ill health
It is impossible to say that either is a more valid description of
ill health than the other, because they measure different things
• Concerned with the whole spectrum of disease and ill health
Mild can be the father of the severe.
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Fig. 2.2 Relation between systolic blood pressure
in middle-aged men and the risk (age-adjusted)
of suffering fatal coronary heart disease (CHD)
or stroke in the next 18 years (Whitehall Study).
They may be real, but they are likely to be delayed and to come to only
a few of those who seek them.
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Mass measures and individual
measures
• Mass scale:
health education by the mass media is necessarily
indiscriminate
• Individual level
car seat belts
High-risk strategy More efficient preventive policies
Reasonable or not
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The shape of the dose-effect
relationship
Two issues concerning the shape of the dose-effect relationship
that are critical for preventive policy:
threshold
Risk
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Exposure
Dose–effect curve is critical for
the planning of control policy
threshold-free
threshold
hazardous
most people
small problem moderation is good,
extremism is bad
feel tired and weak
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should be reduced if possible
The limitations of research
• “Relative risk”(for aetiology) is only for researchers; decisions call for absolute
measures.
• What we need to know in order to determine policy is not simply “Is there an
effect?” (answer “yes” or “no”), but rather “How big is the effect?”.
Unfortunately, in order to estimate magnitude with any useful degree of
precision often requires a very large study.
On power and sample size for studying
features of the relative odds of disease.
JAY H. LUBIN AND
MITCHELL H. GALL
Measured the effects of low-dose radiation by Explored the requirements for a case–control
following the mortality outcome among 39,546 study to discover whether the relationship
workers over an average period of 16 years between natural exposure to radon and an
excess of lung cancer was linear or curved.
Confidence limits on the results were wide! This requires 24,054 cases of lung cancer!
We all need to learn how to live with uncertainty, including the scientific
experts and the policy-makers. 21
Needles in haystacks—an uncommon
exposure to a serious risk
• Suppose (and it is mere supposition) that the fluoridation of water
supplies were to increase the incidence of gastric cancer by 1 per
cent. Undetectable
imply about 100 attributable deaths in Britain each year
• A true and important effect being lost to sight when it is
surrounded by larger neighbours.
Common Accept
Exceptional
Alarm
or new
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Conclusions
• In practice, research studies may lack the size and power to be
able to tell whether or not a threshold effect exists, or to
indicate how much benefit can be expected from reducing the
exposure to a widespread low-level risk.
We must learn to live with uncertainty and to be
satisfied with best judgements.
• It is common to find that the burden of ill health comes more
from the many who are exposed to a low inconspicuous risk
than from the few who face an obvious problem.
This sets a limit to the effectiveness of an individual
(high-risk) approach to prevention.
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Prevention for individuals
and the high-risk groups
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Prevention for individuals and the
high-risk groups
• Prevention
• Clinical care
• High-risk preventive strategy
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• Illness is a personal and not a collective event: it
happens to individuals, and statistics mislead by
presenting only the totals.
• Each of patients suffered severe personal distress
target on the individuals
Example: fund-raising appeals are best accompanied
by a picture
(of a person in need, preferably a child)
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Prevention and clinical care
• The clinician who treats a sick person has an opportunity
to use the occasion for prevention as well as cure.
The medical consultation can provide an effective opening
for prevention.
• It is unfortunate that many consultations are still
dominated by short-term thoughts of treatment, to the
exclusion of a concern for future health.
- familiar clinical skills (screening and immunization),
- outside the regular medical range (management of problems
relating to alcohol, diet, or stress)
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The high-risk strategy
• Action for individuals commonly implies first some
means of identifying those in special need
some form of screening assessment
Example: reducing house dust and house dust mites
in homes with an asthmatic child
Risk factors
measured as a continuous score
dichotomized in order to
identify a ‘high-risk’ group
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Motivation
• The strong attraction of the high-risk preventive
strategy is that intervention is matched to the needs
of the individual.
• medical examinations of nearly 20 000 middleaged
male civil servants
• we recalled only those smokers whose examination
had given evidence of exceptional risk
with success rates of around 10 percent from
routinely given antismoking advice
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Identifying risk: screening
• Screening was developed as a means of identifying
early disease, such as mass radiography to detect
tuberculosis, with the objective of earlier and
perhaps more effective treatment
• The information required for risk assessment may
sometimes
require no special search vs. multiple problems of ethics,
organization, and expense arise
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Strengths of the high-risk
preventive strategy
3. It is readily accommodated within the ethos and
organization of medical care
the man is regarded for
the rest of his life as ‘a
A man with suffering patient’, accommodated
pain in neck from within the familiar
hypertension medical care organization.
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Strengths of the high-risk
preventive strategy
4. It offers a cost-effective use of resources
most diseases involve only a minority
most people need not be troubled with preventive measures
5. Selectivity improves the benefit-to-risk ratio
• Every intervention must carry some costs and a possibility of adverse
effects. If the costs and risks are much the same for everybody, then the
ratio of benefits to costs will be more favourable where the benefits are
larger.
diagonosis (occasionally)
• Eg. Amniocentesis Down syndrome abortion of a normal fetus
• The risk is only justifiable in a high-risk pregnancy: an older mother,
and after non-invasive biochemical tests of alpha-fetoprotein, unconjugated
oestriol, and human gonadotrophins have proved positive
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Weaknesses of the high-risk
preventive strategy
1 Prevention becomes medicalized
A man with walked away from that encounter bearing a
pain in neck label ‘hypertensive patient’, which he must
now wear for the rest of his life
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Weaknesses of the high-risk
preventive strategy
5 Problems of feasibility and costs
• A policy cannot be properly assessed until quantitative answers can be
given for at least these major questions:
1. effectiveness and safety of the intervention
2. acceptability, response and compliance for screening intervention
(long-term, where appropriate)
3. total costs of preventing one critical event to medical services to
participants (in physical, social, and emotional terms)
6 The contribution to overall control of a disease
may be disappointingly small
• How much of that problem it can solve will depend principally on the
ways in which risk and exposure are distributed through the population.
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Thank you for your attention!
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