Geoffrey Rose’s Prevention Paradox

blue and red lines in a graph

Think about the vaccination. To be effective for everyone, each individual should take the vaccine; the higher the number vaccinated better the protection for everyone.

Geoffrey Rose, who coined the concept as the prevention paradox framed it as follows in 19811;

“A measure that brings large benefits to the society only offers a little to each participating individual”.

Arguably, experts consider the concept the best public health concept ever formulated.

In addition to the mass vaccination, Rose used another public health intervention to explain the concept: Seat belt use2.

“A measure that brings large benefits to the society

offers a little to each participating individual”

Rose, G. 1981. ‘Strategy of prevention: lessons from cardiovascular disease’. 
British Medical Journal, 282, 1847-18511.

To convince us about the utility of the prevention paradox, Rose used two evidence-based scenarios2.

I: Most heart attacks occur among those with lower risk.

Look at the following bar chart, which I created using Rose’s data2, which he had obtained from the UK Heart Disease Prevention Project.

As we can see in the above bar chart, as many as 32 per cent of all heart attacks have occurred among those having risk factors alone. On the other hand, only 12 per cent of all heart attacks have occurred among those with the highest risk of a heart attack: Those having both risk factors and chest pain (ischemia).

How can we explain this? The answer is simple; those with the highest risk of a heart attack are fewer in number than those with lower risk.


However, the debate on the population strategy’s utility to prevent coronary heart disease continues. Much later, Douglas Manuel et al.3 argued that the high-risk strategy could also be as effective as the population strategy in coronary heart disease mortality reduction3. Their arguments were based on the following concepts;

  • The coronary heart disease prevention strategies should be based on the population risk distribution; Using Canadian Heart Health Survey data, they argue that the risk is concentrated in a modest proportion of the population.
  • As a result, population-based strategies should evaluate first the baseline risk distribution of a population.
  • Risk screening methods have now improved because multiple risk factors are used.
  • Treatment guidelines are potentially as effective as population strategies.

However, the above arguments depend on the wide-scale applicability of treatment methods and adherence to medications.

Still, following Rose’s analogy is valid and irrefutable. He said,

High-risk approach is analogus to famine relief, which feeds the hungry but does not tackle the causes of famine (p.47).

Geoffery Rose, The strategy of preventive medicine. 1992. Oxford Uni. Press.

It is more so when we acknowledge the modifiable root causes for many non-communicable diseases: Socioeconomic, and political determinants of health.


Then, Rose uses another well-illustrated example burrowing data from Alberman et al.4

Example 2: More babies with Down syndrome are born to women younger than 34 years.

Now, look at this graph, which I created using data published in the same paper2.

As we can see here, of all babies with Downs Syndrome, 71 per cent were born to mothers aged 34 or younger although the individual risk is much lower. In contrast, only 29 per cent of such babies were born to mothers aged 35 and above. In this instance, Rose convincingly demonstrates that the high-risk approach does not work here.

Later, Norman Kreitman demonstrated evidence supporting the prevention paradox regarding alcohol-related problems.

What does this evidence mean?

Rose summarised these findings as follows:

“A large number of people at a small risk may give rise to more cases of disease than the small number who are at a high risk“.

Geoffrey Rose, Sick individuals and sick populations, International Journal of Epidemiology,
Volume 30, Issue 3, June 2001, Pages 427–432, https://doi.org/10.1093/ije/30.3.427,

Here, it is clear that screening for high-risk is not going to be effective in this instance; it requires a population-based approach.

As mentioned before, the population approach is not without its own problems. I mentioned some of those above in regard to the progress of high-risk screening tools such as the Framingham screening tool for coronary heart diseases.

Another critic says that the population approach can exacerbate social inequalities5.

References

  1. Rose, G. 1981. ‘Strategy of prevention: lessons from cardiovascular disease’. British Medical Journal, 282, 1847-1851
  2. Geoffrey Rose, Sick individuals and sick populations, International Journal of Epidemiology, Volume 30, Issue 3, June 2001, Pages 427–432, https://doi.org/10.1093/ije/30.3.427
  3. Manuel DG, Lim J, Tanuseputro P, Anderson GM, Alter DA, Laupacis A, Mustard CA. Revisiting Rose: strategies for reducing coronary heart disease. BMJ. 2006 Mar 18;332(7542):659-62. doi: 10.1136/bmj.332.7542.659. PMID: 16543339; PMCID: PMC1403258.
  4. Alberman E, Berry C. Prenatal diagnosis and the specialist in community medicine. Community Med 1979;1:89–96.
  5. Katherine L. Frohlich, Louise Potvin, “Transcending the Known in Public Health Practice”, American Journal of Public Health 98, no. 2 (February 1, 2008): pp. 216-221.

Author: Prasantha De Silva

A specialist in Community Medicine board-certified in Sri Lanka and a research analyst in Canada

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