Do We Really Need Any More Evidence That Prevention is the Answer?

A man is walking along the bank of a river when he noticed someone drowning. He jumped in and helped the person reach the shore. Almost immediately, he saw several others in need of help. They were fully dressed, obviously not planning to go for a swim. Fortunately, there were people on the bank who could assist with the rescues. Suddenly, a woman who’d been helping began to walk upstream. “Hey, where are you going?” shouted the man. “We need you.” “I’m going to see why people keep falling into the river in the first place,” she replied. As it turned out, the bridge at the head of the river had a hole in it, and this was the source of the problem. The hole was repaired, and additional drownings were prevented.

Upstream public health parable reprinted from Prevention Diaries: The Practice and Pursuit of Health for All by Larry Cohen

I’ve spent my entire career in public health; 30 of those years have been in injury and violence prevention. I’m ashamed to admit that for much of the early years, I had a difficult time describing what I did to friends and family. What is even more ironic is that my undergraduate degree is in Public Relations, and the first seven years of my career was as a public information officer – meaning, it was my job to provide information about public health issues and how to stay healthy. I’m not sure if that speaks to the failure of my undergraduate degree or my inability to apply those principles to my job!

Recently, I started reading Upstream: The Quest to Solve Problems Before They Happen by Dan Heath. I met Dan Heath in 2008 when he was the keynote speaker at the Safe States Alliance Annual Conference. Heath and his brother, Chip, had just published Made to Stick. The brothers have since authored the following New York Times bestselling books, Switch: How to Change Things When Change is Hard, Decisive: How to Make Better Choices in Life and Work, and The Power of Moments: Why Certain Experiences Have Extraordinary Impact. I think all of the books are worth reading, so it was a “no brainer” that I would read Upstream.

When I heard Heath speak in 2008, he good-naturedly chastised those of us in public health for being “bad” at messaging. He actually showed a typical Power Point slide from a public health professional that featured “alarming” statistics on a public health issue. He explained that public health professionals are so compelled by those statistics that we believe everyone else is, too. The real problem is that those statistics aren’t really compelling to anyone but public health professionals.

Even after hearing that keynote in 2008, I have continued to fall into the “compelling statistics” trap, which is evident in annual reports and other communications that my team has published. It is clear by my own evaluation of my efforts to educate decision makers about the need for “upstream” approaches that those efforts have failed.

As Heath points out in Upstream, we often get “stuck in a cycle of response.” He said we are so focused on putting out fires, dealing with emergencies, and handling one problem after another, that we never get around to fixing the systems that caused the problems. “We are so focused on saving the drowning kids in the river that we fail to investigate why they need saving at all,” Heath writes.

While downstream approaches are also important, they are not fail-proof. I frequently use a slide attributed to my friend, Larry Cohen, that says medical care is not always the answer because it comes late in the process after disease is present or an injury has occurred, and it cannot always restore health.

The injury and violence prevention field is filled with success stories of upstream solutions; many of which are documented in While We Were Sleeping: Success Stories in Injury and Violence Prevention, written by Dr. David Hemenway. One of the success stories that Dr. Hemenway describes is the introduction of poisoning prevention packaging. In the 1970s, baby aspirin poisoning of children less than 5 years of age decreased more than 70% in only 3 years following adding safety closures to aspirin packaging. Adding child-resistant packaging to a variety of other products (e.g., antifreeze, drain cleaners, oven cleaners, lighter fluid) resulted in a 67% decrease in poisoning rates in less than 10 years. This upstream approach was much more effective than educating caregivers to be vigilant in watching a young child at all times or even locking their medicine cabinet after every use. Today, we have moved even further upstream with blister packaging and subtoxic doses in medicines. I often use a slide developed by Susan Baker, professor emerita at the Johns Hopkins University Bloomberg School of Public Health, that depicts this type of upstream solution.

The problem is that while upstream solutions are generally more effective, they can often seem more complex. As result, people resort to what they believe is easier and doable. As I’ve learned through my study of systems thinking approaches, we often opt for technical solutions (ones that can be fixed with existing knowledge, such as fixing a broken arm). However, many of the societal issues we face need adaptive solutions (ones that require new discoveries, new knowledge, and new way of thinking).

Twenty-five years ago, a group of visionary leaders in Dallas County used adaptive thinking to address an increasing problem. In 1991, Dallas was facing a crisis. Injuries and trauma-related deaths had increased by 38% over previous years. Trauma-related injuries were growing at such a rate that by 1995, the number of trauma patients would eventually exceed the capacity of Dallas area hospitals to treat them.

Something had to be done – but not the same things that had always been done.

In 1992, more than 100 area health, government and business leaders examined the issue and developed a unique plan to address the problem. Led by Dr. Ron Anderson, former CEO of Parkland Health & Hospital System, Dr. Compton Broders, an emergency room physician at Texas Health Resources, Dr. James Carrico, former Chair of Surgery at UT Southwestern, and Dr. Charles Sprague, former President of UT Southwestern, the leaders established the Injury Prevention Center of Greater Dallas (IPC) in 1994 to implement upstream primary prevention strategies in the community to prevent the car crashes, burns, drownings, falls, child abuse, intimate partner violence and other injuries from ever occurring. These leaders chose to invest in prevention.

For 25 years, the IPC adhered to the guiding principles of using data to drive the selection, implementation of evidence-informed interventions, and evaluation of these strategies. We have developed and implemented prevention strategies through a health equity lens and in partnership with the communities we serve. At the very core of our efforts has been evaluation and community involvement. We are proud of the fact that many of our interventions have led to documented decreases in deaths due to motor vehicle crashes, older adult falls, residential fires, and violence. But we have also been good stewards of our limited funding. When evaluation showed that interventions were not successful in reducing deaths and injuries or increasing safety behavior, those interventions were not continued. Our commitment to evidence and outcome evaluation have resulted in our efforts being recognized nationally, as well as internationally, with more than 65 scientific presentations, 27 peer-reviewed articles and publications, and nine national and local awards. Along with our partners, the IPC led the effort to have Dallas designated as an international Safe Community in 1996 – the first urban city in the world to receive the designation and the first U.S city designated. Dallas was re-designated in 2007, 2011, and 2017.

As John Auerbach, President of Trust for America’s Health, said in a quote in Upstream, “We under-invest in the services and policies that would keep people healthier so that they would not develop those illnesses or have the injuries or suffer from premature deaths that we know could be avoided.” Not only is Auerbach correct about the under-investment in prevention, Heath points out that often public health efforts suffer from a punishment for success. He also quotes Dr. Julie Pavlin, a physician with experience running global health programs, who says, “In public health, if you do your job, they cut your budget.”

Heath says one of the “most baffling and destructive ideas about preventive efforts is that they must save us money.” Again, I have fallen into this trap and have tried to provide examples of costs saved by injury prevention efforts. While this is not my area of expertise, I have relied on credible studies by injury economists such as Dr. Ted Miller to provide this information. However, Heath says that “nothing else in health care, other than prevention, is viewed through this lens of saving money.” He says this is “madness.” The reason to prevent disease and injuries shouldn’t be because of financial returns, says Health, but because of the moral returns. He says we shouldn’t sabotage upstream efforts by subjecting them to a test we never impose on downstream interventions. Amen!

As I said earlier, my expertise is not in cost-benefit analysis. What I do know is that for the 12 years that I have been the Director of the IPC, our hospital has provided less than $500,000 each year to support the IPC. During that same time period, we have secured almost $5 million to supplement our efforts.

In 2013, the cost of injuries and violence in the United States was $671 billion; a new fact sheet from the Safe States Alliance reports that cost is now $840 billion. In 2013, the estimated cost of injuries and violence in Dallas County was $5.3 billion. Even with the significant documented decreases in injury deaths as a result of IPC efforts, unintentional injuries are still the fourth leading cause of death in Dallas County, according to the 2019 Community Health Needs Assessment (CHNA) conducted by Parkland Health & Hospital System and Dallas County Health and Human Services (DCHHS). Injuries and violence are also still the leading cause of premature death in Dallas County. Clearly, there is still much work to be done, yet injury and violence prevention strategies are absent in the CHNA Implementation Plan. That is on me.

As I reflect on our current crisis around COVID-19, I hope that this teaches us that short-sighted decisions to cut public health programs for perceived immediate gains can have catastrophic results in the long-term. I own my ineffectiveness in messaging the need for the IPC or showcasing our successes and value. I hope that the next generation of injury and violence prevention leaders learn how to do that better.

It has been one of my greatest privileges to lead the IPC for the past 12 years. I will be forever grateful to the founders, former leaders and staff of the IPC, and to all of our many partners for this opportunity. Today and always, my work with you will be a “moment of awe.”