Time to get serious about prevention. Remove a pump handle.

Like transparency, equality and democracy in politics, prevention of disease is a motherhood and apple pie issue in medicine– everyone is in favour of it, so long as it doesn’t involve actually doing anything as committed as mounting a serious public health programme or spending millions on research.

This truism takes on a new urgency with the looming threat of Alzheimer’s – a horrible disease which an increasing number of us is set to develop. What are we to do? There is no drug to treat it despite spending billions to find one. Help. Disaster. Nightmare. Well actually there’s now growing evidence that it may be possible to halve the number of cases with prevention. What we need to do is to take prevention seriously.

This is the topic of an opinion piece in the Daily Mail today by Professor David Smith, dementia expert at Oxford that I ghosted for him. It’s  heartfelt plea for a shift in focus from the failed, and fabulously expensive, search for drugs to building on growing evidence that prevention could well make a big difference.

 How many billions would a pill be worth?

A 25% drop in the number of cases by 2020 just by applying what we already know is certainly plausible. Imagine if you could do that with a drug! What a flurry of press reports there would be. What a furious round of debates on the right price – 100 pounds a week? 20,000 pounds a year? How much would be reasonable to spend on such a boon? How much might the research have cost? How much should the drug company be able to make on such a pill?

The one certain answer is – lots. So what happens when there is a reasonable case for saying we might be able to do the same thing, maybe fairly cheaply with dietary and life-style changes? The short answer is almost nothing. As Professor Smith reveals the spend on prevention research by government research bodies and charities is about one penny for every 1000 pounds on drugs.

Oh course the sophisticated response is: “Well what do you expect? There’s no money in telling people to eat more sensibly and exercise; of course it is a Cinderella research ghetto.” But is it really that simple? Would we think it was OK if people didn’t get light or heating because it was just not worth it for the privatised utility companies to deliver it? Or that police didn’t respond to 999 calls from houses off the beaten track. “Yes I know she said she was about to be stabbed by a psychopath but any trip beyond a ten mile radius is just not cost effective.”

 Only 1% on track to cut Alzheimer’s risk

There would be outrage if such service provider’s didn’t have their licenses removed. Yet saying: “Well a properly funded programme might well save a 100.000 people from suffering from Alzheimer’s but frankly we just can’t make enough money implementing it,” is apparently acceptable.

By a nice co-incidence Professor Smith’s clarion call in favour of prevention was strongly backed up by the results of a study that took 34 years on the benefits of five familiar elements of a healthy lifestyle: taking regular exercise, not smoking, eating a healthy diet, having a low alcohol intake and maintaining a low body weight . Doing just four of those, according to the study, which involved nearly two and a half thousand people, slashed the risk of dementia and cognitive decline by at least 60 per cent. That shows just how powerful prevention can be.

So does it really make sense to give it a favourable nod and then park it on the shelf when you could find out who was most at risk and devote some of those drug billions to not just advising them but actively ensuring that they changed their lifestyle? And, as Professor Smith’s paper described, there is plenty more with promising evidence that you could try – keeping your blood pressure down, ensuring you had a good level of B vitamins, adding vitamin D to your diet and so on.

 Remove the pump handle

Surely the time has come to adopt what I’m calling the Pump Handle Approach in memory of the Victorian doctor John Snow who in 1854, in the middle of a cholera epidemic removed the handle from a water pump in what is now Broadwick Street in Soho London.  He had noticed that the number of people dying from the disease was heavily clustered round that pump and reckoned its water was somehow involved in infecting them, although how was still a mystery.

It took a long time but this was the impetus for a programme of public health, building sewers, ensuring clean water that lowered mortality rates and made certain epidemics a thing of the past. We now have a new body called Public Health England. If implementing a programme of prevention that could have a dramatic impact on dementia isn’t on their agenda. they might as well disband themselves now.

At this point the “Nanny State” argument is usually wheeled out: “We don’t want the state interfering in our lives, telling us what to eat and when to exercise. Whatever happened to freedom of choice?” Leaving aside the fact that many of the same people who want to keep the nanny states’ fingers out of our dinner plates are perfectly happy to have it listening to all our phone conversations and email traffic, we know two things:

 Baby Boomer’s last stand

That without proper support and help people won’t adopt even those few simple behaviours – the Welsh study has found that just 1% of the population currently do all of them and that percentage had been the same for the past 30 years.

That without an active intervention to slow down the rise of Alzheimer’s the current NHS funding crisis is going to look like a lottery win compared with the amount of cash that will be needed in 20 years’ time.

This is going to be the Baby Boomers last stand. We know staying healthy is the best way to boost the odds of an enjoyable and productive old age. As 90 looms, who on earth wants be wheel chair bound, rattling with pills for prevention, pills for treatment and pills to deal with the side effects of the prevention without any evidence at all we are actually going to benefit. Let’s start removing those pump handles right now.