Have You Heard of “Primordial Prevention”?

Originally posted 5/31/2011

I never had, until I started thinking about a post on prevention and went to John Last’s Dictionary of Epidemiology to get started. His basic definition is “actions aimed at eradicating, eliminating, or minimizing the impact of disease or disability,” and includes primary, secondary and tertiary prevention. Last defines primary prevention as “protection of health by personal and communal efforts such as enhancing nutritional status, immunizing against communicable diseases, and eliminating environmental risks such as contaminated water supplies.”

I’ve given a lot of thought to the issue of prevention this spring, especially since writing about the National Prevention Council’s Strategy Framework. In that post, I applauded the Framework’s call for Healthy Environments (such as affordable housing, employment opportunities, efficient transportation, good schools, and effective policing) but cautioned against interest group sidelining of these “Cross-cutting Priorities” in favor of the seven behavior-related “Priority Areas” which are more closely related to the primary prevention definition shown above.I was pleased with the Council’s May 24 Webinar discussion, which indicated a new recommendation in the “Empowered People Strategic Direction” to include “improving income, education, and employment opportunities.” I believe critical upstream factors should be central to all models of health, from the Prevention Framework to the Triple Aim. In the CDC’s Community Guide to Preventive Services, the Social Environment is one of 18 topics with systematic reviews. Yet only three reviews currently exist in this critical area: early childhood, culturally competent healthcare, and housing. The brevity of the list speaks volumes to what we consider important and where we have invested our research dollars.

So I was delighted to read that John Last’s definition of prevention includes a relatively recent classification called “primordial prevention”:

Primordial prevention…aspires to establish and maintain conditions to minimize hazards to health…it consists of actions and measures that inhibit the emergence and establishment of environmental, economic, social and behavioral conditions, cultural patterns of living known to increase the risk of disease.

This is, of course, the basic message of Link and Phelan’s seminal article on social conditions as fundamental causes of disease. I am a strong proponent of precision with terminology, because understanding informs and drives action. I sometimes worry that the more classic definition of prevention is too rooted in the lifestyle modification efforts of the past 40 years so that equal attention is not given to the upstream social determinants — or that it leads to taking the comfortable position that since improving income and education is so difficult we leave it to others (such as letting the Treasury and Federal Reserve worry about unemployment for us).

I hope no one doubts that I strongly support the work of the National Prevention Council and consider its strategy work fundamental to improving population health. But I also hope that a limited understanding of its name doesn’t get in the way. The Council cannot fulfill its cross-sectoral purpose unless specific goals and objectives for educational quality, for job creation and economic development, and for controlling health care costs are given equal or higher priority as those for immunizations, food deserts, smoking, and physical activity.

The time has come for “primordial prevention” to take center stage, along with public and private policy and resource allocation to reflect improved understanding of the many factors that drive health.