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Posts Tagged ‘prevention’

A few weeks ago, in September 2019, Spain’s south-east was hit by a coldfront, flooding several villages and cities along the Segura basin. The images of devastation were breath-taking. One of the areas that suffered the most damage was the San Javier-Los Alcázares villages in El Mar Menor.

By no means was it an unexpected event. The Spanish Meteorological Agency had warned of the possible devastating effect of the coldfront. Was the damage due to the fact that the area is not considered floodable?

Directive 2007/60/EC of the European Parliament and of the Council, of 23 October 2007, on the assessment and management of flood risks states in Article 7.5 that “Member States shall ensure that flood risk management plans are completed and published by 22 December 2015”. Spain in general, and the Confederación Hidrógráfica del Segura (entity in charge of the management of the basin) in particular, has complied with the provision of the article and, in March of 2014, issued the flood risk maps.

Let’s have a look at the one for the area in question in which the red marks mean more floodable areas:

And know have a look at Google maps of the area:

Just notice that the red on the first picture coincides almost exactly with the built-up areas of the villages of San Javier and Los Alcázares. So, the area was clearly floodable.

Maybe this event has been an isolated one and that is why nothing has been done to prevent flooding. Wrong again! In 2016 there was also extensive flooding in the area and six historical floods have been reported in the area according to the flood risk maps.

So, why has nothing been done? Why do residential buildings exist in an area that is floodable and that has gone through extensive damage several times in recent years? It may not be due to climate change but, whatever the underlying reason, the fact is that Spain is going through a period of more heat waves and more flooding. And, sadly, the fact is that nothing has been done and nothing is being done.

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Dealing with the unexpected is always difficult. It is difficult for the individual, and it is more difficult for society. Faced with the unexpected, predicting how people behave becomes almost impossible.

Imagine a building on fire. A lot of individuals will shout out the window for help, making the situation more problematic. Others will run to save their relatives, endangering more lives. Some individuals will even try to be heroes, but with out the proper training and equipment they will end joining the body count. Hopefully, some of the individuals will stay calm, close all windows and doors, and wait for the fire department to arrive; these will be the ones who will, most probably, survive. There is another group of individuals, those who will have their minute of glory in the evening news, reporting on all the things that they haven’t seen and spreading false information or, if you prefer, “fake news”.

How can we make a mass of people behave in a rational way? How can we be certain that people, when faced with the unexpected, will react in a way that will not cause more harm?

I can only think of one solution, and it is something that has been tried for centuries: teaching people how to behave. In other words: prevention. Certainly, prevention has been on the menu for a long time and, still, few people act rationally. We must conclude that the way we are trying to bring prevention to people is not the correct way or, alternatively, we are not reaching most individuals.

Since public authorities and NGOs spend quite a few euros on prevention campaigns, let’s not assume they do not know what they are doing. As a matter of fact, there are quite a few examples of very good media campaigns. We are going to focus on the second cause: not reaching most people. We have reached a level of information about almost anything that, to say the least, is overwhelming. But most of the time we must look for the information, the information does not come to us. The information is there but we will seek it out only if we are aware of our needs.

Take earthquakes: Unless we live in certain areas of the world, no one will seek information about how to behave in case of an earthquake. The result is that in San Francisco only very strong earthquakes cause human casualties, but a mild earthquake in south-eastern Spain in 2011 caused 9 deaths and 324 injured. Why? Because we, as a society, have failed to reach out to every individual in the region.

Reaching out to each individual and transmitting proper behavior in case of an unexpected situation should be the main objective of Civil Protection (Civil Defense in some countries). It means making effective use of the risk maps that most countries have; identifying the most vulnerable individuals within the area; and reaching out to those individuals and the population at large so that they know how to behave in case of emergency. No small task, but until we devise an effective system to accomplish that, every time there is an incident, there will be talk about “we should update our protocols for emergency response” and real prevention will be, again, forgotten.

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And it looks like we are losing the battle. According to “Healthcare expenditure statistics” from Eurostat, “[The] highest share [of total healthcare expenditure] of current healthcare expenditure [related to preventive care] in 2014 was recorded in Italy and the United Kingdom (both 4.1 %), while at the other end of the range, shares of less than 1.0 % were recorded in Romania (0.8 %) and Cyprus (0.6 %).” At the other end “curative care and rehabilitative care services incurred more than 50.0 % of current healthcare expenditure in the vast majority of EU Member States”

It may be that this is the right balance, but allow me to doubt it. And my doubts grow as I focus on the demographic change taking place in Europe. The baby-boomers are getting older and we are not doing anything about it, despite the fact that it is probably a generation ready to embrace a healthier and more active life than previous older generations.

I have been wondering, since I started working for the healthcare and social sectors, why it is that prevention does not get the attention of our policy makers.

Many explanations come to mind. Of course, simply saying “they are stupid” is the easy one but I refuse to fall for it. I strongly feel that anybody who has attained a position of responsibility may have many faults, but being stupid cannot be one of them; they would never have reached that position of responsibility.

The urgency of solving the immediate problem may be one of the reasons; after all, if somebody has an acute illness something urgent has to be done. It is a plausible explanation but, if that were the case, policy makers would never plan for the future building new roads or housing developments since they would be too busy repairing the existing road network or the old houses in inner cities.

I am afraid that highways are built because they make the news. I am afraid that most of the things that our policy makers do are geared towards a 30 second appearance in prime time national TV news. If that assumption is right, then it is clear that the opening of a new hospital (curative and rehabilitative care) is a better news item than the establishment of a prevention scheme that does not require any new buildings, or any new expensive and photogenic equipment. It requires only brains and hands, probably the least photogenic tools of the healthcare process and, probably too, the most ignored by policy makers.

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Why is it so difficult to convince older people to adopt gadgets and new behavioural patterns that are meant to make their lives healthier and richer? A person who has not ever read will find it difficult to enjoy reading when turning 65. Behaviour is one of the most difficult things to change; ask any smoker or drinker. And it gets more difficult as we age. Habits form our core identity. As we age we tend to rely more and more on our way of doing things and tend to confront any change with the utmost suspicion.

This behavioural inertia is also ingrained in society. Almost every socio-health care system is based on a pattern of attending social and health problems. Care systems are traditionally designed to repair our ailments. If you have a problem we will take care of you. Don´t bother us if you just feel that probably you will have a problem in the near future; we don’t have time for it!

The combination of both behavioural patterns, personal and social, results in a rejection to adopting anything that means to change our old ways. Change then comes forcefully, meaning we have to change because there is no other way. Any change is, then, a public proclamation of some kind of unavoidable evolution in our system. If I am using a walking stick, it means that I am now frail. I am telling everybody that now I am frail, everybody assumes I am going downhill. Outcome: I will not use that dammed walking stick even if I fall!

If walking sticks became fashionable, as they were in the last century, my ailments would be stealthy; I would be using the walking stick just like everybody else, only I really need it.

If care systems insist on putting all their efforts into solving problems – tackling mainly acute problems-, there is no chance that we can incorporate new habits into the population. I know that for years there has been talk about the need to introduce prevention into our care systems. I know also that very little has been done. If you are in doubt, compare the amount that any system is investing in obesity induced illnesses and the amount spent on preventing obesity. I recognize also that the opening of a new acute hospital makes headlines with a nice picture of the Minister of Health, while a program for changing eating habits in children in an out of the way school does not make even a tiny article on page 45 of the local newspaper. Nevertheless, we all know that prevention is the only way to face a brighter future.

Prevention means that, as soon as possible in the person’s life, the system will help to change habits in order to avoid future complications. With that in mind, we will be able to introduce say, healthy eating apps that will be assimilated into our everyday life. The person will rely on the app when feeling at loss for ideas for tomorrow’s lunch. The odd search will become a habit, and the app will start recording what food is chosen, and letting the person know when he/she is eating more meat than necessary.

Compare this process with today’s. Today, I would go to the doctor when I felt sick, he will spot that I am eating a very unhealthy diet and recommend a complete overhaul of my eating habits. He may recommend an app to help me keep track of what I eat. I will struggle to follow the diet and will not use the app. My mind is telling me that I have been eating a lot of meat ever since I was young and I have enjoyed every minute of it. I will keep it that way till the grave, even if it means the grave closes nearer.

I think that the only way to success is to be able to induce a behavioural change in our target population. We know that behavioural changes are easier the younger the person is. We should then aim at incorporating as soon as possible into daily life those elements that will contribute in the future to a longer and healthier life. Get your walking stick today; do not wait for when you really need it. Or in a more up-to-date fashion, start getting acquainted with apps and other ICT gadgets today, before you really need them and feel old and battered.

From the developer/entrepreneur point of view, your customers are the social-health care systems; convince them that only by prevention will they have spare resources to attend the ageing society; change their behavioural pattern from solving acute problems to preventing problems. I know it is a long and burdensome process but it is the only way that your products will make it to the market, to those who need them.

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Efficacy in the provision of care coupled with efficient use of scarce resources is the goal of any social and health care system. Or is it?

Governments feel hijacked by their constituencies. They feel the need to provide quick answers to problems that, in most cases, their constituencies are not even aware of. Politicians feel the need to do something, and that something has to be readily visible. If you were an average  politician, what would you prefer? A front page picture in the paper of the inauguration of a hospital, or a long interview in the middle pages explaining how you have bet on primary care? You can fill in the blank ________________.

And yet, we all use a lot more primary care services than those of an acute hospital, no matter if we are young or old. We rely for our well-being on proximity services: social and health primary care. Only on extreme occasions do we use an acute setting.

Furthermore, primary care is focused on prevention, as opposed to remedial actions provided by acute hospitals. To top it off, prevention is recognized as the basic pillar of efficacy in care and efficiency in the use of resources.

And then, why is it that prevention is the black swan of care? I can only think of one answer and it is not a pretty one: our politicians need quick fixes and they have neither the knowledge nor the willingness to confront complicated problems.

Can we do something about this? I would like to think that we can. The constituents, or in other words the professionals and users of the socio-health system, should make their voices heard loud and clear: we would like a system that helps us to prevent ailments, not a system that only takes care of us when it is too late.

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