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