* This is the first in an occasional series of articles on must-read, indispensible papers in public health.
Forty-one years ago when I started working in public health, there was a parable someone would reliably quote in the first hour of any seminar. The 1895 poem The Fence or the Ambulance by Joseph Malines is a paen to prevention, and the importance of building low-cost fences at the top of metaphorical cliffs rather than leaving them unfenced and spending a fortune on ambulances and treatment facilities to care for all those who fall.
The parable is more relevant than ever today, with American biomedical ethicist Albert Jonsen rebirthing and expanding it as The Rule of Rescue in 1986, and Monash University’s John McKie and Jeff Richardson writing the definitive analysis in 2003. Any list of seminal papers essential to the decoding of modern debates about health would be incomplete with that paper.
Each year, in my first introductory lecture to our Masters students on What is public health? I start with a photo of stranded fish, flapping helplessly on a shoreline, waiting death.
I explain that a mother and her son are walking on a beach and see the fish being washed up on the shoreline. The mother begins to throw fish back into the water, saving their lives. The boy asks what the point is of saving a few when inevitably hundreds or thousands more will immediately take their place. The mother replies that while this is true, that each fish she saves will be in no doubt that being helped to live was a good thing.
I tell this story to emphasise that personal acts of generosity and helpfulness can make important differences to others. Civilised societies always value individuals and rescuing individuals in need is nearly always virtuous.
But the problem is that while such small numbers of “fish” are being thrown back in the sea for a second, often limited chance, thousands more are being washed ashore.
Public health has found many ways of greatly reducing death, disease and suffering before it starts. But the rule of rescue helps us understand why the task of advancing prevention higher on political priorities is Sisyphean: with every effort to advance prevention up the steep hill of sustained funding, the next crisis in health care where limited funding is implicated, invariably attention to sick individuals will triumph. Funding will roll back down the hill for prevention far more rapidly than it will for health care.
The essence of the rule of rescue is that public and political priorities will always see the immediate needs of the sick and injured as more important. It is unlikely to matter if a national public awareness campaign is funded next month or even next year, but it will very much matter if emergency services are cut or inadequate on the day that they are needed.
Joseph Stalin infamously said that one death was a tragedy, while a million deaths were a statistic. The beneficiaries of prevention are statistical non-victims, not self-identifying individuals whose pain, neglect or imminent death can call attention to their plight.
Everyone in need of health care has a name, and nearly always a family and friends who care deeply about their welfare. But I cannot name a single individual who I know for sure will be a direct beneficiary of a preventive policy that will reap its benefits into the future.
Reality TV medical programs have attracted high ratings for years. But imagine if the producers of such hospital dramas decided to develop a parallel series on saving lives through prevention.
Immediately problems would arise about how to make it work as television. “Tune in next week to see if Bev’s blood pressure is still down!” Swallowing pills or generational cultural shifts about smoking just don’t have the same dramatic televisual appeal as a patient like your child navigating a life-or-death operation.
As I wrote in the BMJ in 1996,
The paradox of prevention is that it succeeds when nothing happens. Few people sit up in bed at 3am astonished at the thought they have not yet been being badly injured or were born without a preventable birth defect. It’s hard to make riveting TV out of a change across twenty years on the slope of a graph showing disease incidence. While every grateful patient knows their doctor’s name and hangs on every bedside word, who has any idea of those behind the epidemiological detective work that first leads to understanding of what causes disease? Or of the years of unglamourous expert committee work and community trials of ways to best have people change health related behaviours?
Fortunately for prevention, many of the most effective, evidence-based interventions are largely cost-free. Policies, laws, regulations, mandatory product standards and institutional practices not just in the health domain, but in other almost every other sector such as education, transport, urban planning, and housing, can quietly act as “passive prevention”. This greatly reduces the risk and severity of disease and injury, as I pointed out in my 2013 Conversation piece 150 ways that the nanny state is good for us.