Geoffrey Rose’s Prevention Paradox

Geoffrey Rose’s Prevention Paradox states that large numbers of people must participate in a preventive strategy for direct benefit to relatively few.(1) Libertarians have obfuscated this issue by claiming that mass preventive prescriptions, even in “sick populations,” are an infringement on individual rights. This mis-states the case and distorts the Rose Paradox (Rose 1981).

First, it misses crucial points about the population or mass causes of disease, as well as about the population strategy required for primary prevention. For example, about half of adults in western societies develop hypertension during their average 75-year life spans. Half of these, in turn, die from coronary disease and stroke. It is quite likely that, with effective primary prevention of hypertension in the first place, they would die later and healthier. Whatever the case, their lifetime cumulative risk of CVD is surely not remote. Thus, it is not just “the few” who benefit from prevention strategies.

The Rose Prevention Paradox has also been misused to disparage the population strategy of primary prevention in favor of identifying only adults at high risk and focusing all efforts on them, to avoid “penalizing” the masses. This view, in strong favor among some academics and clinicians, presupposes that dealing with the high-risk adult segment of the population would not only take better care of the problem, it would do so more efficiently. In fact, there is much evidence that such an approach is neither a complete nor an efficient one.

First, there is the relative imprecision of identifying high-risk individuals; then there is the late, unexpected, and often fatal first manifestation of the disease, sudden death. Finally, there is the predominantly socio-cultural determination of average risk factor levels in the population, so that the not-yet-at-high-risk, young people, for example, are missed entirely when a prevention strategy is confined to medical strategies among high-risk, middle-aged adults. Under these conditions, the epidemic simply rolls merrily along.

Another contention of those I believe distort Rose’s Prevention Paradox is that social decisions that play individual rights against social responsibility, or that promote health, creating a demand for preventive services, amount to an Orwellian Big Brother state. To the contrary, I suspect that an educational, motivational approach to personal and societal change is the only truly democratic way for an open and informed society to arrive at policy.

It is a distortion that prevention policy is considered a surreptitious attempt to deprive people of a better life, one earned by industriousness, or that preventive efforts penalize the masses for the sake of a few. Those of us closely involved with the population strategy of prevention and health promotion find that freedom from the “bondage” of personal addictions, freedom from enslavement to commercial manipulations, independence from the economic determinants of unhealthy food products and environments, and liberation from the confines of unhealthy cultural traditions, all represent no deprivation of basic freedoms. Rather, they amount to an unshackling from dependencies and from economic decisions made for us, largely without concern for our health and mainly outside our personal control.

Because of the realities of the Paradox, however, in which effective primary prevention does involve some change among many people, Geoffrey Rose has quite properly insisted on the primacy of demonstrated safety for all community-wide health interventions. He again formulates clearly a view that I and others have long argued less effectively: that a critical guideline to the safety of a population intervention is its compatibility with a lifestyle to which humans are evolutionarily adapted. Historically recent, “man-made” lifestyle initiatives, such as sedentariness, calorie-dense fatty and salty foods, and perpetual caloric abundance, along with the wide use of tobacco and of medications, all are now recognized to lead often to physiologic maladaptations. The criterion of “adding something foreign” to this evolutionary experience (e.g. pills, and fat and sugar substitutes) should, according to Rose, require another magnitude of evidence for wider safety.

In this view, with which many of us would agree, it would be questionable whether any long-term, regular use of a medication or a food additive/substitute, by large numbers of the public, in the management of such mass phenomena as mildly elevated blood pressure or blood lipid levels or body weight, or for helping to stop smoking, could ever meet a priori safety and ethical criteria for a mass public health strategy. [ed. Such prognostications fail miserably. The world is now awash in “Statins,” and in variations of the “Polypill.”] (Henry Blackburn)

[footnote 1: The precise Rose definition is: “a measure that brings large benefits to the community offers little to each participating individual.”]

Reference

Rose, G. 1981. ‘Strategy of prevention: lessons from cardiovascular disease’. British Medical Journal, 282, 1847-1851.