Why Prevention Is So Hard

We know what we should do. But we don't.

When it comes to prevention, I like to quote one of my all-time favourite philosophers, Homer Simpson; when his wife Marge advised him not to drink a jar of vodka and mayonnaise, he responded:

“That’s a problem for ‘Future Homer’.

Man, I don’t envy that guy.”

We all know that prevention is better than cure.

But why is it so hard to follow that advice?

We know that adhering to the fundamental principles of good nutrition, exercise, sleep, and emotional health can delay the onset of most diseases that are likely to result in our death.

And yet. And yet.

Applying basic lifestyle interventions can extend a person’s life by 10 years, which as a percentage of someone’s life is an incredibly long time.

But as a society, we repeatedly fail to implement that which we know our ‘future selves’ will benefit from.

We consistently undervalue prevention.

The article pictured below is from the Welcome Trust Museum in London and makes the case that our healthcare systems need to focus less on “disease and cure” and more on “health and prevention”.

Looking closely, you will see that this article was written in 1979.

Why is it that over 40 years later, we are stuck in the same place?

Because even though the benefits of prevention are obvious, its implementation is complex.

Let’s look at some factors that might explain things.

Incentives

As humans, we are incentive-based creatures. As Charlie Munger says:

“Show me the incentive, and I will show you the outcome.”

The problem is we are incentivised to make all the wrong decisions. The image below shows a beach scene on Coney Island in the late 1800s. Notice anything different to what you might see today?

Sure there are fewer bikinis, but everyone in the photo is of relatively normal weight.

Coney Island - 1896. Creative Commons

Do I think the people of New York in the late 1800s were biologically different to the people of today?

No. I don’t.

Do I think the food environment we are in today is very different?

Yes. I do.

In the last 100 years, people have not changed. The environment has.

More importantly, the incentives to engage in poor lifestyles have changed.

We eat excess amounts of nutrient-poor food because we are highly incentivised to do so.

We choose driving over walking because, well, it’s just the easier option.

We get less sleep because our digital devices have endlessly available, highly addictive content to keep us up at night.

We suffer worse emotional health not because we choose to but because we are incentivised to compare ourselves to others ‘Living Their Best Lives, or at least a highly selective airbrushed version of it.

In so many ways, we are worse off, not because we choose to be but because we are highly incentivised to be.

All of this may not be our fault, but it sure is our problem.

When the incentives all favour poor outcomes, we cannot rely on willpower alone as a broad-scale solution. Sure, some will take on a very high level of personal responsibility and tackle this by themselves (I highly advocate that you do this); however, most people will need their incentive structures changed.

We need to get to a point where making the right choice is more appealing, not less. That involves changing environments, and that takes time.

But it works.

Remember smoking on airplanes?

Neither do I.

Time Lines

Historically, the majority of deaths were a result of infectious diseases. Think TB, pneumonia, flu and diphtheria. Prevention of infectious disease had a short time course. You eliminated the infectious agent, and the impact was seen in a very short period. Very satisfying indeed.

Today, the majority of people die from non-communicable diseases. Think cardiovascular disease, cancer and dementia. While prevention of these conditions is possible, the time between the intervention and the benefit is much longer than in infectious diseases. Think decades, not weeks.

As humans, we find it hard to appreciate the benefit of something we will experience in the distant future. In psychology, this is known as ‘future discounting’ whereby we disproportionately value a gain in the present compared to a larger gain in the future.

‘That’s a problem for Future Homer’. We have all been there.

The question is, why? Why do we make poor choices when we rationally know that we are likely to experience a negative consequence due to our actions?

Strangers Winning Nothing

First off, one of the biggest challenges in prevention is that the absence of something occurring defines its success. As humans, we do not do well with absences. Try to think of a void. You can’t. You had to fill it with something.

Additionally, the future self you are trying to accrue benefit to might not even be 'you' according to brain imaging research¹. When we think of our future selves, the brain regions that activate are those usually associated with our representations of strangers rather than ourselves. And the further into the future we think of ourselves, the more we associate that person with being a stranger. So, in reality, when we make a poor decision today, the person we believe will pay the penalty won't even be us.

"I don’t envy that guy".

The same challenge arises when we consider issues on a much larger scale, such as climate change. The world will no doubt be very different over the time scale of the next 100 years, but for us to make sure it is not catastrophically different, we need to take action now. Why we don’t is down to the reasons we have discussed already, but in truth, most of us imagine the world’s future inhabitants as total strangers, even though they are likely to be our children.

Prevention is hard. But it works.

In the late 1700s, global life expectancy was 28 years of age.

Today that figure is 72 years of age. It is close to 80 years of age for developed regions such as Europe and the US.

Over 300 years, the average life expectancy has increased dramatically. But what is important to note is that the average life expectancy has improved mainly because people are not dying at very young ages, as opposed to people living exceptionally long periods of time. In 1850s England, people did live until 80 years of age; there were just very few of them. Today, most people are surviving into their 80s. The reasons for this are multifactorial but are heavily influenced by improved sanitation and the prevention of infectious diseases.

We know that prevention works.

We know that prevention has extended the average lifespan by decades when applied to controlling infectious diseases.

We know that the diseases that now account for our death, cardiovascular disease, cancer or dementia, are preventable, at least in their premature form.

We know that we can improve average lifespans even further and possibly even extend maximum lifespans to a degree.

And yet.

And yet.

1. Saving for the future self: neural measures of future self-continuity predict temporal discounting. Soc Cogn Affect Neurosci. 2009 Mar;4(1):85-92.