Efficacy in Public Health

Without question, the most efficacious measures in dealing with disease have been those that have addressed the matter in concern at the population level of life. Not being without political difficulties at implementation, they have also been, by far, the most cost effective.

Among the diseases so controlled, are the acute infectious diseases such as polio and measles, however the only chronic life-style-related preventable disease (CLiPD) to fall into this category is dental caries. Even though fluoridation of the water supply reduced the incidence of dental caries by 70%, and thus the need for either, labour intensive (expensive) surgery for individual teeth (dental surgery), or the expensive edentulous condition ('expensive' in terms of quality of life not only the dental functional context but also at the often hidden but ubiquitous and highly relevant psychological context as well), were both markedly reduced. These therapeutic, functional and psychological costs exist in all CLiPDs and are debilitating symptoms of society at the macro economic level; the population level of life.

As the vaccines enhance the immunological barrier to infection so fluoride enhances the dental tissue barrier against the onset of dental caries. In a semantic sense however, neither vaccine nor fluoride are pure prevention. Strict definition of prevention is removal of cause; neither vaccine nor fluoride does. They can, therefore, be considered as therapy rather than prevention, and here lies the political difficulties of their implementation. The mass approaches for dealing with the acute infections with fatal consequences are more readily accepted by the plebiscite than that of the only chronic disease so attempted; the early signs and symptoms of chronic diseases being painfully silent. There have been cases where fluoridation has been implemented, shown as efficacious (at least at the scientific level), and yet the plebiscite has insisted on its removal from the town supply! I project that any macroeconomic approach to deal with any or all of the CLiPDs will be hindered at the outset by a large political 'hurdle', not the least of which will be the model set out below.

Macro economically, the clinical profession (including medical dental and other paramedical) has a monopoly, in the 'business' of disease. In that the populace tends not to consult until after painful symptoms, the profession can be considered a lazy monopoly when it comes to CLiPDs.  Any other business which is monopolistic (say for example selling peas as opposed to beans), markets its products or services with use of the mass media in order alter demand towards its products and services, to maximize its revenue, its productivity, its efficiency and its profits. There are several established successful marketing models which relate marketing budget to turnover, ranging from launching new product (largest budget <35% of projected turnover) to maintenance (lowest budget. > 5% of turnover). At the macroeconomic level, efficiency is achieved by maximizing turnover.

With CLiPDs macroeconomic efficiency would be achieved by minimizing turnover, by avoiding the expensive therapies such as surgery, radiotherapy etc, by maintaining quality of life and by avoiding premature death. As the populace is uneducated and unmotivated en masse, then marketing the diagnostic and preventive services of the profession with respect to CLiPDs, using the established marketing models in order maximize demand for those diagnostic and preventive services should ultimately grossly reduce incidence of CLiPDs and possibly eliminate some. Thus the vast intellect and resources which is currently wasted on these preventable conditions because they are preventable would saved and channeled more productively, and similar macroeconomic efficiency be achieved by maximizing cost reduction.

When viewed globally, that which is here proposed is the only realistic macroeconomic model to deal with CLiPDs. For macroeconomic entities such as Government publicly, and Health funds privately, to respond only at the microeconomic level is, if anything, by design nurturing an increased incidence of CLiPDs. By telling an individual 'pay us your premium and we'll look after you if you get sick' is tantamount to saying 'don't worry about looking after yourself we'll do it for you'!!  With every respect, as Medicare really only pays for cures it should be called Medicure, and as the Health Funds really only pay for disease, they should be called Disease Funds. These transfer payment systems evolved from a socialistic fiscal basis a century ago, and have remained essentially unchanged. Conversely diagnosis, especially causal diagnosis, has improved quantumly over that century and it is time to cease taxing those who do care for themselves and thence benefit society, in favour of those who do not look after themselves and thence become a liability to society. And further, still with every respect, to shuffle statutes from public sector to private or vice versa amongst these antiquated systems is like shifting the proverbial deck chairs on the Titanic.

The candidate model is then to market the three 'D's (Diagnosis, Diet and Discipline), imitating the extant commercial models using a realistic marketing budget, aimed to achieve efficacy, elimination of the CLiPDs and a quantum reduction of the health vote by phasing out the obsolete existing macro-to-micro transfer payment systems.

Needless to say it would take some considerable guile for an elected politician to delete the current obsolete system and replace it with the candidate proposed here, where the CLiPDs are to be removed from the current cure based payouts replaced by hard sell preventive services of the professions, and the sufferer goes private. Not only does the diagnosis have to be accurate as to cause, but also when one considers a phase-in process there is a long 'tail' (as in indemnity liability) and just how does that diagnosis draws the causal line. Difficult questions but they should not question the logic of the candidate because they are only implementation issues. Looking and moving forward the candidate is an obvious course for public health efficacy. However the politician may reasonably ask 'What evidence is there of the efficacy?'.

Research is required which should be ongoing to monitor and allow adjustment as efficacy appears. Such research requires a baseline study and periodic review.  Ideally an unsullied and contained population should be used; New Zealand would therefore be most appropriate in Australasia having a realtively contained media. Of the CLiPDs dental caries and periodontal disease are the most available to measure the marginal changes in sign and symptom because of these diseases anatomical readiness for observation, being therefore the least expensive to observe. From the ensuing analysis the most efficacious marketing budget to turnover ratio could be established thus creating a formula to transpose onto the other CLiPDs. Such an exercise requires the co-operation of the practitioners who will be able to service the newly created demand (the private dentists).

The politics of such could work thus. Approximately 65% of the population does not attend the dentist regularly for diagnosis. A marketing campaign to sell the preventive services of the dentists will have spin off with respect to the tertiary (fillings, crowns, root canals etc) and quaternary (implants) preventive needs which in turn will significantly increase the turnover of the participating dentists, therefore justifying their individual contribution to the campaign. On the first instance the participating practitioners should pay a percentage of their own turnover in order to be eligible to participate. The relevant continuing education, along with their fiscal contribution will give them the right to display the marketing campaign's logo in their individual practices communications. A difficult first step but once started the original dissenters will have little alternative but to join.

Strong Australasian governmental support, of the overall scheme, from the outset is imperative. Once the efficacy is established through analysis, the politics of replacing the current cure based governmental subsidy with a prevention-based approach for CLiPDs would become more politically easy.