Prevention of the causes of premature illness and death: making it happen
Authors: Geneviève Chêne
Journal: The Lancet Public Health (2017)

“Ensure healthy lives and promote well-being for all at all ages” is the third objective of the UN Sustainable Development Goals. To achieve this goal and its 13 targets, countries must increasingly adopt evidence-based policies, programmes, and interventions for prevention and health promotion. Two of the major challenges moving forward are to conduct cutting-edge research on prevention and to consider health more holistically, while preserving the undeniable contribution of biomedical research and health-care systems to health. Indeed, universal and equal access to the best possible health care is of utmost importance, but is far from sufficient to sustainably improve health of the populations globally. We must also invest in interventions able to reduce the preventable causes of death and chronic illnesses and, by doing so, relieve some of the burden on the health-care system and thus further support its sustainability. Where do we start? Of interest is to compare the performance of two simple national level indicators: life expectancy and premature mortality. Life expectancy tends to reflect the organisation of and access to health care, whereas premature death, or deaths that occur before a person reaches an expected age (ie, 65 years), tends to reflect exposure to risk factors that might be preventable. Take France for example; France fares well compared to other Organisation for Economic Co-operation and Development countries when it comes to life expectancy overall and at age 65 years, but only averagely when it comes to premature mortality.1Organisation for Economic Co-operation and DevelopmentPotential years of life lost.https://data.oecd.org/healthstat/potential-years-of-life-lost.htm#indicator-chartGoogle Scholar, 2Direction de la recherche, des études, de l'évaluation et des statistiques (DREES)L'état de santé de la population en France. Rapport 2015. Paris: Ministère des affaires sociales, de la santé et des droits des femmes.http://drees.social-sante.gouv.fr/IMG/pdf/rappeds_v11_16032015.pdfDate: 2015Google Scholar In France, as in many countries, a large share of premature deaths are attributable to smoking, excessive drinking, poor diet, or environmental and occupational hazards.3GBD 2013 Risk Factors CollaboratorsGlobal, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2015; 386: 2287-2323Summary Full Text Full Text PDF PubMed Scopus (1932) Google Scholar Moreover, premature mortality increases as we move down the social ladder as individuals on the bottom rungs amass a greater share of these deleterious exposures.4Marmot M The health gap. The challenge of an unequal world. Bloomsbury, London2015Summary Full Text Full Text PDF Scopus (152) Google Scholar We, as a society, have drawn these conclusions thanks to remarkable data collection efforts since the 1950s. Registries, cohorts, and large health surveys have been (and continue to be) crucial observational tools to gather and produce robust evidence about existing and emerging public health issues and a greater understanding of both their determinants and causes. For example, epidemiological research was instrumental in establishing the link between smoking and pulmonary cancer5Doll R Bradford Hill A Smoking and carcinoma of the lung.Br Med J. 1950; 2: 739-748Crossref PubMed Scopus (1280) Google Scholar, 6Trichopoulos D Kalandidi A Sparro L Lung cancer and passive smoking: conclusion of Greek study.Lancet. 1983; 322: 677-678Abstract Scopus (100) Google Scholar or vascular diseases,7Wolf PA D'Agostino RB Kannel WB Bonita R Belanger AJ Cigarette smoking as a risk factor for stroke: the Framingham Study.J Am Med Assoc. 1988; 259: 1025-1029Crossref PubMed Scopus (673) Google Scholar but this evidence alone did not directly translate to a reduction in the prevalence of smoking. Now is the time to capitalise far more actively on the investments made in observational tools and use the best scientific knowledge and experience to design research on preventive interventions. A 2016 report8Levy DT Yuan Z Luo Y Mays D Seven years of progress in tobacco control: an evaluation of the effect of nations meeting the highest level MPOWER measures between 2007 and 2014.Tob Control. 2016; (published online Dec 12.)DOI:10.1136/tobaccocontrol-2016-053381Google Scholar on the introduction of tobacco control policies and the subsequent reductions in the prevalence of smoking and smoking-related deaths is just one example of how this approach can work. The next action is therefore to promote the highest quality population health intervention research9Potvin L Petticrew M Cohen ER Population health intervention research: developing a much needed science of solutions.Prev Med. 2014; 61: 114-115Crossref PubMed Scopus (13) Google Scholar, 10Campbell M Fitzpatrick R Haines A et al.Framework for design and evaluation of complex interventions to improve health.Br Med J. 2000; 321: 694-696Crossref PubMed Scopus (2372) Google Scholar and move towards more evidence-based programmes, practices, and policies. This next step is very ambitious for many reasons. First, we must identify innovative preventive interventions, including technologies, able to address the most common risk factors for premature death. Second, we must conceive of novel methodologies to assess these (commonly) complex interventions and identify which components are working, if any. Third, we must characterise health systems and organisations that facilitate the implementation and sustainability of these interventions. Fourth, we must ensure that effective interventions also promote equity, so that prevention reduces health inequalities rather than increases them. Fifth, we must constructively overcome the attempts from vested interests to discredit researchers and their findings when they pose a threat to the status quo. Sixth, we must mobilise adequate funding for this type of research, which, because of the complexity of these interventions, is costly. National strategies for health research need to identify prevention as a priority and raise adequate funds to catalyse high-quality prevention science. The efforts of the EU Commission, as exemplified by the Horizon 2020 programme, and other international funding agencies should be complemented by these national efforts to meet the needs of population health. We can no longer delay investing in the necessary research assessing complex interventions to improve health without harming those populations most at risk. I declare no competing interests.