Benjamin Franklin is famous for many things, one of which is his often-repeated advice that “an ounce of prevention is worth a pound of cure”. He wrote that in 1735, and it was surely not new advice at the time. But like today, it was harder no doubt to mount a plan of action to prevent problems, than to try and deal with the consequences when they happened. Of course, the right information and education is necessary to act, but it’s not a sufficient condition to ensure that action follows.
Amazon UK currently lists a staggering 136,558 book titles on diet, and Amazon.com has even more (170,120). Just knowing what to do to prevent ill health, doesn’t mean that anyone follows the advice. Public Health England (PHE) are taking a different approach with the launch of One You, a web-based health platform to provide advice and support via apps and social media nudges. We need to learn from that experience, whatever happens, as well as from other popular devices to change health behaviour (e.g. activity trackers).Prevention in healthcare is all the more challenging because it requires action by many actors and at many levels of aggregation – the individual, the family, the community, the healthcare system, the State and so on. This challenge was simply and clearly set out in the case of infectious diseases and antimicrobial resistance in the final interim reports by the AMR Review team published yesterday, titled Infection Prevention Control and Surveillance: Limiting the spread and development of drug resistance. Investments in infrastructure are how society coordinates important work for prevention; in this case, the authors highlight the importance of improvements in water, sanitation and housing to reduce the burden of communicable disease that may require antibiotics (to which we can add transport, as anyone regularly travelling by Tube can confirm). You can’t get a punchier punchline than “increasing access to sanitation in a country by 50% is correlated with around nine and a half years of additional life expectancy for its population” (p.7). We wonder why these investments aren’t happening as a matter of course, why they aren’t prioritised in development plans, but the challenges remain.The AMR Review team look beyond these familiar foundational investments to also address the need to coordinate investments in practice and protocols to address the risk of superbugs in healthcare systems. In this case, the UK offers a case study of what can be achieved with focused response, considering the work to reduce potential infection from methicillin-resistant Staphylococcus aureus (MRSA). Making it everyone’s priority seems to have been a successful means to coordinate action to drive prevention. Unfortunately, there are only so many things we can focus on at the same time, either individually or organisationally. Without a doubt, the ability to identify the most critical threats for antimicrobial resistance (AMR), and to do so in time to prevent serious harm, is critical for healthcare systems; but this ability seems almost superhuman. As the report sets out, it may indeed be beyond human calculation, and this is the imperative for future and globally coordinated action – a global surveillance system for drug-resistance infections. “If we cannot measure the development and spread of drug resistance, we cannot manage it”. The challenges of ‘Big Data’ also figure here: how to create common data standards to connect initiatives globally; how to ensure informed consent and agreed access of data; how to address the areas of activity and geography that have yet to be addressed; and how to manage the governance and cost of such a system. Although there are many details yet to explore, it clearly is a core investment for prevention.Although Ben Franklin’s advice has been a familiar phrase over the decades for me, what I didn’t know was that it was his argument for a fire service for Philadelphia. Philadelphia in the early 1700s was plagued by fires, and Franklin noted that despite the hue and cry that would attend each fire, a lack of organisation meant that destruction of human life and property continued. Writing anonymously to his own paper in February 1735, The Pennsylvania Gazette, as an “old citizen”, he argued for prevention by the individual (“…I would advise ‘em to take care how they suffer living Coals in a full Shovel, to be carried out of one Room into another…”), by the professional (arguing that chimney sweeps should be licensed by the city) and for the organisation of prevention, arguing for the establishment of a “club or society of active men belonging to each fire engine, whose business is to attend all fires with it whenever they happen.” He was successful and the first volunteer fire department in the United States – the Union Fire Company – was established on December 7th, 1736. However, the historical accounts note that this was done “under Franklin’s goading” and it was almost two years after his letter. In other words, just knowing what to do, doesn’t mean it is going to happen. You have to make it happen.The analogy between fire prevention and antimicrobial resistance (or drug resistance, as may be more easily communicated as the Wellcome Trust have described) has been made already (1) and it stands up to scrutiny. We have a chance to get the ‘fire alarms’ and ‘fire engines’ in place to fight AMR. We have the understanding to share to prevent illness through individual action and societal investment. We just have to make it happen.Benjamin Franklin, the Fireman By Charles Washington Wright, 1850Ward, Andrew. 2015. 'AstraZeneca urges antibiotics investment shake-up', Financial Times, November 15, 2015, section Medical Science.