Sick individuals and sick populations by Geoffrey Rose

Review by Sidney Ortun Flament

This article has revolutionized the health promotion approach. The impact goes beyond the field of epidemiology and into that of public health generally. Doyle, Furey and Flowers (2005) affirmed that the central messages transmitted by Rose remain highly relevant to modern public health policy and practice [1].

Geoffrey Rose compares the ‘high-risk’ and ‘population’ strategies for prevention of disease.

‘High Risk strategy’. The ‘high risk’ approach is an individual clinically oriented approach: the health professional focuses on the individuals with the highest levels of the risk factor and prescribes them medicine to prevent diseases (for instance in case of hypertension he tries to prevent, among others, cardio vascular diseases).

The main advantages of this strategy are:

  • the intervention may respond to the needs of the individual
  •  thus, the patient motivation to follow the treatment is likely to be high

The main weaknesses are:

  • the success of the intervention may be palliative and temporary as it is difficult to predict disease incidence  at the individual level
  • the contribution to the control of the disease at the population level might be small
  • the social characteristics such as cohesion in society and economic conditions that can have profound effects on health might not be correctly taken into account through an individual approach, the intervention may be behaviorally or culturally inadequate
  • it may only encourage medicalized prevention
  • it has a poor ability to predict which individuals will benefit from the intervention [2].

‘Population strategy’. The ‘population’ strategy is a public-health oriented approach which consists in shifting the population distribution of a condition in order to prevent a higher number of cases. It supposes that ‘a large number of people at a small risk may give rise to more cases of disease than the small number who are at high risk’.

The main advantages of this strategy are:

  • the changes are happening to the whole population
  • the societal effects of a distributional shift may be large
  • it considers the functioning of the society as a whole

The main disadvantages are:

  • it brings only a small benefit to each individual, for example, to prevent one death due to a motor vehicle accident, many hundreds of people must wear seat belts. –Conversely, an intervention which brings much benefit to an individual may have a small impact in the population.
  • thus, individuals might be scarcely attracted
  • it requires major changes in the whole mode of functioning of society which can be really slow and unlikely. Indeed, social and economic pressures such as the cigarette and food companies lobbies and their marketing strategies tend to increase the incidence of risk factors such as cholesterol and blood pressure via the increase of the consumption of junk food and cigarettes

Rose’s paper deals with the major issue that the causes of incidence are not necessarily the same as the causes of individual susceptibility. Indeed, an individual might become alcoholic because of depression, peers social pressure, or the love for alcoholic drinks. However, populations have high and low consumption of alcohol for other reasons such as religion, tradition, availability, income, taxes, etc. This can also be illustrated in the developing world; poverty is one obvious cause of the incidence of infant mortality and morbidity associated with malnutrition and infections. A lack of vitamin A intake via food intake can induce xerophtalmia. Often, the first intervention considered is oral vitamin A supplementation. However, wider determinants of this problem such as poverty and maternal education, which are dictated by cultural values, should be primarily considered.

“Rose’s contribution cannot be overestimated. The insight that characteristics of populations cannot be reduced to individual characteristic and that both may have important impacts on health suggests new realms for health promotion and disease prevention. But Rose’s conceptualization requires a shift in thinking, particularly in contexts where individual autonomy and choice is given great priority.” [3]

“Twenty years after Geoffrey Rose published his classic paper, the central messages remain highly relevant to modern public health policy and practice. The individual and population approaches are fundamentally different but both are needed. Recent examples of powerful population approaches prove Rose’s point that norms can change benefiting the most deprived. Individual approaches have also succeeded but their protection of the most deprived communities is limited. Consumerism in health and over-reliance on individual approaches risk widening health inequalities.”[1] For instance, high-risk prevention strategy tends to be oriented to the privileged. The financial resources are diverted form primordial prevention to the diagnosis and treatment of cardiovascular risk factors and coronary heart disease and diabetes among the emerging urban population of poorer countries. Thus, in poorer countries, the dominance of high-risk strategies consumes resources that should be used in existing maternal and child health programs.

Rose’s seminal 1985 article has made a huge impact on the fields of epidemiology and public health. The central message that has been integrated into the field is that ‘a large number of people at a small risk may give rise to more cases of disease than the small number who are at high risk’. This lesson has profound implications for intervention and prevention strategies. It thus has been incorporated into many research contexts through an understanding of the difference between measures of absolute and relative risk.

References:

[1] Y G Doyle, A Furey, J Flowers, Sick individuals and sick populations: 20 years later, South East London Strategic Health Authority and European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, UK; Eastern Region Public Health Observatory, Institute of Public Health, Cambridge, UK, 2005

[2] Porta M, ed. A dictionary of epidemiology. 5th. edition. New York: Oxford University Press, 2008. ISBN 978-0-19-531450-2 and ISBN 0-19-531450-6

[3] – S Schwartz and R Diez-Roux, Commentary: causes of incidence and causes of cases- a Durkheimian perspective on Rose. Int. J. Epidemiol. 30 (3): 435-439. 2001

Sick individuals and sick populations, by Geoffrey Rose, 1985 International Journal of Epidemiology. Access:  http://ije.oxfordjournals.org/content/30/3/427.long

Review published: October 2013, HPC

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