Preventive Practices Necessary for the New NormalBy Rodrigo Brugada | Mon, 06/14/2021 - 18:50
COVID-19 arrived in an already sick country, with obesity, diabetes and cardiovascular disease rife among the population. This, among other things, led to worse outcomes, higher mortality and will possibly have a profound impact on Mexico’s economy. What could have been done differently to face COVID-19 and what can be done to ensure the subsequent health crises do not hit the country as hard?
Current State of Public Health
The Mexican healthcare system is highly fragmented and segmented, which leads to difficulties in ensuring universal coverage and adequate access to health services, according to the Inter-American Development Bank. Moreover, its care practices have been characterized by being primarily reactive in their approach. Not only do health providers allocate very few resources to prevention practices, but every education/formation opportunity focuses on healing, curative or corrective care.
Mexico’s health reality is also different depending on the region. For example, there is a substantial difference between what ails the southeast and what ails the north of the country. This polarization is also fueled by geographical, societal and individual differences, such as purchasing power, gender and ethnicity. These conditions are social determinants of health (SDH), as defined by WHO, which play a paramount role in the health-disease processes that people go through.
Two persons with diabetes may have completely different outcomes based only on whether they had access to health services or whether those were quality services. These environmental and societal conditions may impact health directly (for example, living in an area with high hydric stress), but may also shape and modify other factors that in turn may affect health (like economic disparities leading to someone having a low wage and thus having a low-quality diet). SDH can also impact health immediately (like the lack of proper regulation in construction leading to a collapse during an earthquake) or they may contribute to a worsening in quality of life in the long term (for example, having to work several jobs leading to an accumulation of stress and musculoskeletal wear-and-tear).
Healthcare systems, in general, have historically aimed to identify diseases and subsequently treat them. Mexico is no exception and the domestic health system has mainly dedicated its efforts to providing diagnosis, treatment and rehabilitation in some instances. Only recently has Mexico started doing preventive work. As stated by Javier Picó, partner at LifeSciences Consultants, “It is time to reevaluate the role of private health “investors,” beyond each country’s “Healing Systems” (incorrectly named “Health Systems”).”
Changes in Epidemiological Profile
When analyzing the evolution of health problems through time, a trend appears: improvements in infrastructure and sanitation bring about a decrease in infectious diseases, which leads to an increase in life expectancy. This, however, brings negative consequences in other aspects, like cardiovascular and metabolic disorders. Mexico is currently going through its shift toward a higher prevalence of chronic diseases as cardiovascular and metabolic diseases become the main culprits of rising disease burden, which is the impact of a health problem in a population measured by financial cost, mortality, morbidity and quality of life (QoL). These diseases have their roots in a westernized lifestyle, mainly through the sum SDHs and risk factors, including a high-caloric density and low-quality diet, sedentarism and exploitative work.
Prevention remains a handy tool not only in the mitigation of current problems but in ensuring a reduction in future ailments. Taking the case of a person with a significant genetic predisposition for insulin resistance, it is possible to determine different scenarios in terms of treatment:
- Nothing is done and the natural course of the disease runs unaltered. In this case, the person in question would develop insulin resistance, turn diabetic, develop complications and die because of a stroke or sepsis. In this scenario, individual life expectancy would be shortened and a significant proportion of the person would see a significant reduction in QoL.
- No measures are taken to ensure that the person does not develop diabetes but complications are treated and rehabilitation is offered. In this case, much like the previous scenario, the person would develop complications that would have to be treated. In this scenario, too, individual life expectancy would be shortened (though not as much as in the previous scenario) and a significant proportion of the person would still see a reduction in QoL.
- No measures are taken to ensure the person does not develop diabetes but some measures are taken to modify the course of the disease. In this case, the person in question would develop insulin resistance and probably turn diabetic before being diagnosed as such. A healthcare professional would recommend changing certain aspects of lifestyle and medication would possibly be prescribed. With this, and depending on how well the person follows these recommendations, complications could be postponed or avoided. Thus, life expectancy reduction could be minimal but the decrease in QoL would probably remain or even be greater during the last years of life. This is the current approach of the Mexican health system.
- The person takes specific individual actions to reduce the likelihood of developing insulin resistance. In this scenario, the person would probably develop the condition later in life but may never develop diabetes. In case they do, complications would arrive much later or may not develop at all. Depending on the case, medication may not ever be required, which means life expectancy and QoL would probably remain unaltered.
- Environmental, societal and individual actions are taken to reduce external factors that may lead to developing diabetes, facilitating personal changes to reduce the likelihood of the disease. This shift would not only maintain but perhaps extend life expectancy, while improving QoL. The most important difference against the previous scenario is that there would no need to make a change toward a healthier lifestyle because that would already be the norm.
These different approaches reflect different levels of action regarding prevention. The current academic literature identifies four types of prevention. The first scenario corresponds to complete inaction, which equates to not having any access to health services throughout life. The second scenario corresponds to what is known as tertiary prevention, which aims to soften the impact of an ongoing illness or injury that has lasting effects. In this scenario, direct costs associated with the disease would be high for the person and minimal to the healthcare system, but costs associated with complications would be extremely high. This is because virtually everyone with the disease would develop complications and complications typically involve hospitalization, medication and procedure costs. Also, there is a considerable opportunity cost due to productivity lost to disability and a subsequent lack of opportunities.
The third scenario corresponds to secondary prevention, which involves actions directed at detecting diseases earlier and trying to halt their progression to reduce the impact that would have otherwise occurred. This type of prevention is insufficient to improve health. Its costs for patients tend to be lower (if they have adequate coverage) but are high for the health system. While total costs are lower and outcomes are usually better, there are still costly complications and the healthcare system must provide treatment for patients.
The fourth scenario reflects primary prevention, involving all actions aimed at reducing the likelihood of disease arising in the first place and, as INNSZ’s director Dr. Kershenobich states, “Considering that we have different levels of prevention, we require an approach that includes actors beyond medical professionals.” This is one of the most compelling scenarios for improving outcomes and optimizing healthcare spending. Savings come from fewer people needing treatment and fewer still developing complications. One major caveat for this model is that not everyone has access to primary prevention because of inequality in SDHs. For example, having a higher-paying job allows for free time to exercise instead of working a second job.
The fifth scenario does not correspond to a level of prevention; it instead reflects health promotion efforts. These try to address the root causes of ill health by bringing forth healthier environments and social dynamics that would make primary prevention easier, if not the norm. While this approach is the costliest, it is also the one that saves the most direct spending on health. Its costs come through investing in intersectoral policies to improve SDHs and would be helpful towards other policy aspects not directly related to health.
Where Do We Go From Here?
After the pandemic is over, health systems will have a big choice to make: keep business as usual or shift towards better, more sustainable practices. Whatever is chosen will decide how we manage the health crises to come. SDH and broader inequalities must be tackled to promote prevention. WHO states three key actions: adapting environments for better lifestyles, ensuring good governance for good health and improving health literacy.
The first of these actions entails caring for people’s physical, mental and social well-being, aiming to be an equitable and inclusive society. The process starts with the commitment to put people and health at the center of the development agenda and acing through a multidisciplinary approach that includes urban planning, economic development, social sciences and public health.
Some characteristics of healthy cities listed by WHO include:
- A clean and safe physical environment of high-quality (including housing quality)
- An ecosystem that is stable now and sustainable in the long term
- A strong, mutually supportive and non-exploitative community
- A high degree of public participation in and control by the public over the decisions affecting their lives, health and well-being
- Meeting of basic needs (food, water, shelter, income, safety and work) for all the city’s people
- Access to a wide variety of experiences and resources, with the possibility of multiple contacts, interactions and communication
- A diverse, vital and innovative city economy
- Encouragement of connectedness with the past, with the cultural and biological heritage and with other groups and individuals
- A city form that is compatible with and enhances the above parameters and behaviors
- An optimum level of appropriate public health and sick-care services accessible to all
- High health status (both high positive health status and low disease status)
Ensuring good governance for good health parts from an understanding that health is a process determined by multiple factors outside the direct control of the health sector and that decisions made in other sectors can affect the health of individuals and shape patterns of disease distribution and mortality. Thus, there is a need for national responses that build synergies across sectors, ensuring greater coordination and coherence of policies. The specific framework through which WHO offers to tackle this issue is Health in All Policies (HiAP), defined as “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts to improve population health and health equity.” This approach is considered vital to the achievement of several, if not all, Sustainable Development Goals.
Lastly, improving health literacy seeks to empower individuals and communities to better take care of themselves and be active participants in the decisions that affect their health. WHO defines health literacy as “the achievement of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions.” Thus, health literacy means more than being able to read pamphlets and make appointments. Health literacy is critical to empowerment by improving people’s access to health information and their capacity to use it effectively. People must know about their bodies and the processes they go through to take care of themselves.