What is the role of prevention in health policies?

In which area would you say that pre­ven­tion in health policies is most advanced?

Pre­ven­tion is a very broad area. We tend to dis­tin­guish between primary pre­ven­tion, which is related to the appear­ance of health risks linked to food and pol­lu­tion, and sec­ond­ary pre­ven­tion, which aims to detect dis­eases that can­not be avoided. Primary pre­ven­tion is com­plic­ated because it is out­side the health sys­tem, but patients can bene­fit from it dur­ing their health care. One example is the suc­cess of the “Vigil­anS” pro­gramme, which has been run by psy­chi­at­rists since 2015 and con­sists of call­ing back people who have been hos­pit­al­ised after a sui­cide attempt six months later to find out how they are doing.

In 2018, this pro­gramme helped to reduce sui­cide attempts in the Nord and Pas-de-Cal­ais depart­ments by 10 to 12% in three years, which led to it being exten­ded to the whole coun­try. On the oth­er hand, there are still many missed oppor­tun­it­ies for gen­er­al prac­ti­tion­ers in terms of primary and sec­ond­ary pre­ven­tion. Although they see many people who have attemp­ted sui­cide, in prac­tice few doc­tors under­take spe­cif­ic fol­low-up of their patients, which increases the prob­ab­il­ity of a second attempt¹.

You have worked on addict­ive beha­viour among adoles­cents. Do pre­ven­tion policies in this area go far enough?

In order to be more effect­ive, the fight against psy­cho­act­ive sub­stances has been the sub­ject of inter­min­is­teri­al work between justice, health and cus­toms. How­ever, the res­ults remain insuf­fi­cient for the time being.  In the frame­work of pre­ven­tion policies, we work with young people on how to deal with emo­tions. But teach­ers should also be more involved in these sub­jects. In this area, Great Bri­tain, Canada, and Aus­tralia have suc­ceeded in set­ting up more integ­rated pre­ven­tion pro­grammes. This is prob­ably because ded­ic­ated experts work dir­ectly with the author­it­ies and the ban on the sale of alco­hol to minors is respec­ted. Ice­land has also adop­ted a fairly exem­plary pro­act­ive policy to lim­it the use of psy­cho­act­ive sub­stances among young people. The Iceland­ic mod­el is based on a num­ber of ele­ments that modi­fy the social envir­on­ment of young people at school, in the fam­ily, in the neigh­bour­hoods where they live – and by strength­en­ing the links between these dif­fer­ent circles to con­cretely respect the same rules of non­con­sump­tion in dif­fer­ent spaces, lim­it access to psy­cho­act­ive sub­stances, and foster com­mu­nic­a­tion between these dif­fer­ent areas².

Gen­er­al prac­ti­tion­ers still have an essen­tial role, but do they have the means to carry out prevention?

Yes, their role is fun­da­ment­al. Even if it is true that, as they are becom­ing increas­ingly spe­cial­ised, pre­ven­tion is only a minor part of their train­ing. Moreover, doc­tors can only spend an aver­age of 10 minutes with each patient. Although gen­er­al prac­ti­tion­ers can now pre­scribe phys­ic­al activ­ity to over­weight dia­bet­ics, there is still no eval­u­ation of these pre­scrip­tions. Fur­ther­more, giv­en the med­ic­al inequal­it­ies in the coun­try, oth­er pro­fes­sion­als will have to broaden their fields of com­pet­ence. Nurses will be able to pre­scribe drugs, mid­wives will have to do more gyn­ae­co­lo­gic­al mon­it­or­ing and pae­di­at­ri­cians will have to train in areas such as addictology.

Can the private sec­tor be involved in prevention?

It can be, provided that pub­lic policies fol­low. In France, there is an anti-smoking policy, but fight­ing alco­hol is more com­plic­ated. The gov­ern­ment, which sup­ports the wine industry, did not sup­port the “dry Janu­ary” cam­paign, which calls for no alco­hol con­sump­tion after the New Year. The industry advert­ises, includ­ing on social net­works, to young people, which is pro­hib­ited by law. Apart from actions by the asso­ci­ation Addic­tions France, few com­plaints are filed. The same applies to the food industry, where lob­bies are very power­ful. This is illus­trated by the battle waged by research­ers to have labels such as Nutriscore affixed to food in order to increase trans­par­ency on the com­pos­i­tion of food. A label that has come up against the lack of will on the part of industry.

Your work has shown that social inequal­it­ies in health are aggrav­at­ing factors for obesity and depres­sion. Are these factors being taken into account more?

Health also depends on many social and eco­nom­ic determ­in­ants that lie out­side the health care sys­tem. In this respect, ten years ago, WHO recom­men­ded includ­ing health determ­in­ants in all policies as indic­at­ors to be eval­u­ated. For example, in urb­an plan­ning, in order to meas­ure the impact on the health of the neigh­bour­hood when build­ing a road, or to cal­cu­late the bene­fits of policies to extend patern­ity leave. But it is clear that this sys­tem­at­ic inclu­sion has still not been taken into account. With the pan­dem­ic, it would be even more neces­sary because social inequal­it­ies in men­tal health have increased. So much so that all policies that sta­bil­ise incomes, pro­mote employ­ment and good work­ing con­di­tions can only be positive.

Interview by Marjorie Cessac