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The Strategy of Preventive Medicine
This book explores and analyzes the options for preventive medicine, considered from various viewpoints - epidemiological, sociological, political, practical, and ethical. The uniting theme is the concept of health as an issue for populations as well as for individuals. This has applications
throughout medicine and these are illustrated by a wide range of examples. The book will be valuable to professionals and students in public health, epidemiology and health economics. It will also be of interest to health service managers and planners, clinicians interested in prevention, and all
those concerned with health as a public issue.
throughout medicine and these are illustrated by a wide range of examples. The book will be valuable to professionals and students in public health, epidemiology and health economics. It will also be of interest to health service managers and planners, clinicians interested in prevention, and all
those concerned with health as a public issue.
160 pages, Paperback
First published August 6, 1992
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Displaying 1 - 12 of 12 reviews
January 4, 2023
This is a great introduction to the basic concepts of public health and epidemiology. Rose is highly regarded in his field, and his clear and concise explanations break down the need for a strategy of preventative medicine. If you like this kind of stuff, but are not working in the field, check out Marmot's work. Highly recommend it - it laid a super useful foundation when I embarked on my MPH.
October 24, 2020
Can you tell this book was assigned reading for an MPH class? It’s a very good introduction to a number of key ideas in epidemiology, and would probably make a great (short!) intro text in a beginner class. I was assigned to read this as part of an ethics class, which doesn’t quite make sense, but I’m happy to have read it nonetheless.
Let me begin by saying that I really enjoyed the simplicity of Rose’s book. In fact, the introduction to the 2008 version, co-written by a couple of Rose’s protégés, is unfortunately a bit harder to follow. Rose discusses a number of fairly complex topics in a relatively simple way, enabling a beginner student in public health to easily ascertain his meanings. You do need at least a little bit of background in statistics first, though. The book relies heavily on the concept of the normal distribution, so if you don’t know what that is, the book’s key insights won’t make much sense to you.
Rose’s main goal in writing the book is to argue for a population-based approach to public health, as distinct from one that focuses on treatment of the sickest individuals. Historically, medicine’s purpose has been to treat the visibly ill and infirm, while basically ignoring the rest of the “normal”, non-sick population. But of course, so much of what determines good health is based on structural characteristics in a society, and to fail to medicalize them is to fail to take preventive action. Improvements in sanitation, housing, and working conditions, for example, have greatly improved population health even though these ostensibly fall outside of the medical domain. The last line of Rose’s book is very telling, for he asserts that “Medicine and politics cannot and should not be kept apart.”
What justification does Rose offer for focusing on a population approach, rather than an individual sick one? Rose contends that any health characteristic in a population can be plotted as a distribution, and that more often than not these characteristics take the shape of a normal (or bell curve shaped) distribution. The majority of people will fall into the middle “normal” ranges, with fewer and fewer people representing the extreme values at the tail ends of the distribution. For health characteristics that take a normal shape across all populations, such as weight, blood pressure, student test scores, or alcohol consumption, these distributions can easily be compared with each other to get a sense of how countries differ with respect to different health characteristics.
Rose argues that “the deviant tail of ‘trouble-makers’ belongs to its parent distribution.” At its core, this is a mathematical observation, since the extent of any normal distribution curve will be a function of its mean and standard deviation. In practice, this means that population norms affect the values in the extremes. For example, if the average American woman weighs 166.2 pounds, then the higher ranges of the distribution curve will be higher than in the curve that models weight in Chinese women, where the average weight is a mere 125.2 pounds. Put another way, the percentage of American women who are overweight or obese will be higher than the percentage of Chinese women who are overweight or obese, since the American average is so much higher to begin with. The same can be said of high cholesterol — the higher the average cholesterol in a population, the greater the percentage of individuals who will fall into the dangerous higher ranges. The lower the per capita alcohol consumption, the less likely that society is to be afflicted by problems of alcoholism (since alcoholics represent the extreme upper end of the curve).
Many, if not most, public health interventions take a high-risk approach, whereby individuals identified as belonging to the high-risk portion of the distribution are singled out for treatment, while the “normal majority” is ignored. Such an approach is unlikely to be effective in the long run, Rose argues, since it is only addressing the symptomatic cases that arise from the larger population distribution. Proper, large-scale health interventions should instead seek to shift the entire curve by either lowering or raising the mean, as appropriate. Lowering the average cholesterol in the United States by just a small amount would do more to prevent new cases of stroke that lowering the cholesterol of only high-risk individuals by a substantial amount, for example. This is because risk is distributed across the entire population and not just confined to high-risk individuals.
I won’t delve deeper into the finer points of Rose’s arguments, but suffice it to say that he makes a compelling case for his approach. This is a solid text, suitable for beginners, that still stands up quite well despite being published almost 30 years ago. I’m sure there are newer iterations of these ideas by now, but sometimes it is nice to read the original.
Let me begin by saying that I really enjoyed the simplicity of Rose’s book. In fact, the introduction to the 2008 version, co-written by a couple of Rose’s protégés, is unfortunately a bit harder to follow. Rose discusses a number of fairly complex topics in a relatively simple way, enabling a beginner student in public health to easily ascertain his meanings. You do need at least a little bit of background in statistics first, though. The book relies heavily on the concept of the normal distribution, so if you don’t know what that is, the book’s key insights won’t make much sense to you.
Rose’s main goal in writing the book is to argue for a population-based approach to public health, as distinct from one that focuses on treatment of the sickest individuals. Historically, medicine’s purpose has been to treat the visibly ill and infirm, while basically ignoring the rest of the “normal”, non-sick population. But of course, so much of what determines good health is based on structural characteristics in a society, and to fail to medicalize them is to fail to take preventive action. Improvements in sanitation, housing, and working conditions, for example, have greatly improved population health even though these ostensibly fall outside of the medical domain. The last line of Rose’s book is very telling, for he asserts that “Medicine and politics cannot and should not be kept apart.”
What justification does Rose offer for focusing on a population approach, rather than an individual sick one? Rose contends that any health characteristic in a population can be plotted as a distribution, and that more often than not these characteristics take the shape of a normal (or bell curve shaped) distribution. The majority of people will fall into the middle “normal” ranges, with fewer and fewer people representing the extreme values at the tail ends of the distribution. For health characteristics that take a normal shape across all populations, such as weight, blood pressure, student test scores, or alcohol consumption, these distributions can easily be compared with each other to get a sense of how countries differ with respect to different health characteristics.
Rose argues that “the deviant tail of ‘trouble-makers’ belongs to its parent distribution.” At its core, this is a mathematical observation, since the extent of any normal distribution curve will be a function of its mean and standard deviation. In practice, this means that population norms affect the values in the extremes. For example, if the average American woman weighs 166.2 pounds, then the higher ranges of the distribution curve will be higher than in the curve that models weight in Chinese women, where the average weight is a mere 125.2 pounds. Put another way, the percentage of American women who are overweight or obese will be higher than the percentage of Chinese women who are overweight or obese, since the American average is so much higher to begin with. The same can be said of high cholesterol — the higher the average cholesterol in a population, the greater the percentage of individuals who will fall into the dangerous higher ranges. The lower the per capita alcohol consumption, the less likely that society is to be afflicted by problems of alcoholism (since alcoholics represent the extreme upper end of the curve).
Many, if not most, public health interventions take a high-risk approach, whereby individuals identified as belonging to the high-risk portion of the distribution are singled out for treatment, while the “normal majority” is ignored. Such an approach is unlikely to be effective in the long run, Rose argues, since it is only addressing the symptomatic cases that arise from the larger population distribution. Proper, large-scale health interventions should instead seek to shift the entire curve by either lowering or raising the mean, as appropriate. Lowering the average cholesterol in the United States by just a small amount would do more to prevent new cases of stroke that lowering the cholesterol of only high-risk individuals by a substantial amount, for example. This is because risk is distributed across the entire population and not just confined to high-risk individuals.
I won’t delve deeper into the finer points of Rose’s arguments, but suffice it to say that he makes a compelling case for his approach. This is a solid text, suitable for beginners, that still stands up quite well despite being published almost 30 years ago. I’m sure there are newer iterations of these ideas by now, but sometimes it is nice to read the original.
June 3, 2020
Un clásico imprescindible de Salud Pública. A día de hoy no nos dice nada insólito, pero planteó ideas novedosas cuando se publicó hace 30 años y es una lectura agradable para introducirse y fundamentar conceptos.
Sienta las bases de lo que conocemos acerca de las estrategias de prevención. Habla (y alaba) mayormente del enfoque poblacional de prevención, con afirmaciones clave como que "cambios moderados y alcanzables por el conjunto de la población pueden reducir mucho el número de personas con problemas visibles", si bien lo de "moderados y alcanzables" me parece discutible. Relacionado con esto, también dice que estos cambios aparentemente "duros" son "el precio que necesariamente hay que pagar por el hecho de ser miembro de esta sociedad y no individuo solitario". Creo que esto podría abrir un debate muy interesante.
Por otro lado.
Me ha gustado mucho la reflexión que hace sobre la incertidumbre y la incapacidad de las poblaciones para vivir con ésta, como barrera a la legitimidad de las decisiones políticas en salud ("la certeza no es un requisito previo para la acción"). También tienden a exagerarse las certezas para que el público, cómodo con ellas, sea persuadido en la dirección deseada. Ciertamente lo mejor de este libro son sus posibilidades de debate.
Termina diciendo que para abolir las "desviaciones" en salud hemos de actuar sobre determinantes estructurales (económicos y sociales). Solo así puede favorecerse la libertad que condiciona el estado de salud de tantos colectivos. La medicina y, en general, las ciencias de la salud, tienen que ir para ello de la mano de la política.
Sienta las bases de lo que conocemos acerca de las estrategias de prevención. Habla (y alaba) mayormente del enfoque poblacional de prevención, con afirmaciones clave como que "cambios moderados y alcanzables por el conjunto de la población pueden reducir mucho el número de personas con problemas visibles", si bien lo de "moderados y alcanzables" me parece discutible. Relacionado con esto, también dice que estos cambios aparentemente "duros" son "el precio que necesariamente hay que pagar por el hecho de ser miembro de esta sociedad y no individuo solitario". Creo que esto podría abrir un debate muy interesante.
Por otro lado.
Me ha gustado mucho la reflexión que hace sobre la incertidumbre y la incapacidad de las poblaciones para vivir con ésta, como barrera a la legitimidad de las decisiones políticas en salud ("la certeza no es un requisito previo para la acción"). También tienden a exagerarse las certezas para que el público, cómodo con ellas, sea persuadido en la dirección deseada. Ciertamente lo mejor de este libro son sus posibilidades de debate.
Termina diciendo que para abolir las "desviaciones" en salud hemos de actuar sobre determinantes estructurales (económicos y sociales). Solo así puede favorecerse la libertad que condiciona el estado de salud de tantos colectivos. La medicina y, en general, las ciencias de la salud, tienen que ir para ello de la mano de la política.
March 26, 2020
A sensible and nice to read book on the issues to consider when practising preventive medicine. The bent is sociological and economic, however, that is to be expected given its population focus. It is sensible and well balanced. The main contentions in preventive medicine are around the risks to individuals, the constraints placed upon their autonomy and the inevitable sociologic and economic impacts of preventive interventions.
The entire book can be summarised in the last two sentences. 'The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart.' This is a truism.
Preventive medicine will also have a place if we each desire good health, as individuals or as a community; these are one and the same and cannot exist without one another.
A recommended primer on the topic.
The entire book can be summarised in the last two sentences. 'The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart.' This is a truism.
Preventive medicine will also have a place if we each desire good health, as individuals or as a community; these are one and the same and cannot exist without one another.
A recommended primer on the topic.
September 11, 2020
Rose was wicked smart. I'm not very familiar with the field of preventive medicine, but he broke it down in a way that was easy to understand and backed by science.
Thinking at a population level is not very intuitive - and is even harder for governments - so I can only hope more people read this book.
Thinking at a population level is not very intuitive - and is even harder for governments - so I can only hope more people read this book.
September 13, 2024
Brilliant. Very interesting epidemiological insights about distribution of disease and risk. Also, a powerful support to the idea that public health has to be political, and has to get to grips with the social determinants. Nice
October 15, 2024
The examples are so very dated. Still a classical book for the field.
Read
December 30, 2016Good read. Although we must move beyond prevention to promotion of positive outcomes, not just less bad as he highlighted. He did however, confirm much of the work I do. He agreed, the benefit of prevention is a non-event - NOTHING.
The biggest gain from the book was getting to see how Deming's use of Common and Special Causes enabled a better process and improved outcomes in business can be used to improved public health efforts In much the same way, Rose documented that we need to focus on common causes if we want the best outcomes. However his best outcomes were not bad instead of more good.
A big insight was that in public health we are treating common causes as special causes and as Deming documented, this creates more problems than it corrects. I will work to understand this better and see how it can be used to create more good and better outcomes in public health.
He also sides with Skinner in documenting it is the environment that determines behavior and that of who there person is with. As I continually attempt to do, create an environment that nurtures, encourages and supports health creating actions.
The biggest gain from the book was getting to see how Deming's use of Common and Special Causes enabled a better process and improved outcomes in business can be used to improved public health efforts In much the same way, Rose documented that we need to focus on common causes if we want the best outcomes. However his best outcomes were not bad instead of more good.
A big insight was that in public health we are treating common causes as special causes and as Deming documented, this creates more problems than it corrects. I will work to understand this better and see how it can be used to create more good and better outcomes in public health.
He also sides with Skinner in documenting it is the environment that determines behavior and that of who there person is with. As I continually attempt to do, create an environment that nurtures, encourages and supports health creating actions.
June 25, 2011
Dr. Michael Marmot, Chair of the World Health Organization's Commission on the Social Determinants of Health, once commented that Geoffrey Rose “if heeded, could change the way we think about public health.” Dr. John Frank, previously Director of the Canadian Institutes of Health Research - Institute of Population and Public Health, recently referred to Geoffrey Rose’s book The Strategy of Preventive Medicine as “the most important book you should ever read in public health”.
I couldn't agree more - this is one of my handy references that I attempt to bring in to the class I teach and my work. A very good public health book!!
I couldn't agree more - this is one of my handy references that I attempt to bring in to the class I teach and my work. A very good public health book!!
January 22, 2014
Interesting, but I didn't see any new ideas in it. Except for the ones about the value of human life: it is better to save young adults because they have been making a lot of expenses and have not started to produce yet. It is not that good to save a baby because they are cheap to produce and they can be easily disposed of. And it is not that good either to save an old fella because they are not going to produce anything more and they are cheaper if they are dead. (Says the book, not me!!!)
September 21, 2023
Geoffrey Rose's ideas has been highly influential to my own approach to public health and health promotion, and I enjoyed every bit of this eloquent and powerful book. I try to refer to Rose's philosophy in all of my lectures, and even though it's not exactly new, it still manages to get people to think and see things in a new light.
September 14, 2014
Should be the vademecum of 21st C. preventive medicine, the basis for "Health in All Policy." Prof Rose was one of the pioneers of the idea of mutifactorial life style intervention in preventive cardiology (and stroke). Many clear-cut examples.
Displaying 1 - 12 of 12 reviews