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