Larry Cohen, founder and executive director of Prevention Institute, has been a public health and prevention advocate and pioneer for 35 years. In his latest book, “Prevention Diaries: The Practice and Pursuit of Health for All,” he explores the aspects of daily life that influence our health and argues that a prevention approach offers many common-sense solutions that save lives and money, and reduce human suffering.
Thank you! I like to describe “Prevention Diaries” as the kind of book we prevention advocates can give our friends and colleagues so they understand what we all are doing in trying to advance prevention, and why we are doing it. I draw on my three decades of experience to make a case for building health into the everyday fabric of our lives — from health care to workplaces, urban planning to agriculture. The goal is to create an alternate model of American health care, one less concentrated on treating ailments and more focused on preventing them from developing. Doing this requires a shift in how our society perceives and approaches health — first, to recognizing our overreliance on individual solutions rather than community solutions; then, to building an environment conducive to preventing problems before they occur.
Q: What’s so important about community prevention for improving health?
For decades, the national prevention model was understood primarily as educating people about health and safety risks, hoping they would magically change their behavior. As well-intentioned as educational efforts are, they can never be very effective without simultaneously changing home and community environments, social norms, policies and institutions. We have moved beyond brochures and health fairs. Clearly, family and individual well-being is ultimately the goal, and community conditions are critical in determining an individual’s or family’s health.
The focus on community prevention has steadily grown in the past 40 years as the lessons learned from efforts such as curbing tobacco use, minimizing DUIs, reducing HIV transmission, and increasing healthy eating and physical activity have confirmed the effectiveness of community approaches. Essentially, a focus on changes to the social, cultural and physical environment effectively alters health behaviors and norms, and generates positive health outcomes. Community action also is often the impetus of national-level decisions that vitally shape individual and community well-being — local policy bubbles up.
Although people often experience the impact of illness or injury one person at a time, prevention practitioners have learned that effective strategies must attend to the community and the population as a whole. Indeed, it was the noted prevention pioneer, Dr. George Albee, who rightfully proclaimed, “No epidemic has ever been resolved by the treatment of affected individuals.”
Q: Your book is full of stories. Can you tell us one of your favorite examples from the book about community prevention at work?
It’s hard to pick just one, but I’ll go back to how my journey began. In the 1980s, while working in a county health department in northern California, I was offered a chance to pioneer a new approach: to grapple with multiple health and safety issues simultaneously in the role of director of prevention. I asked myself what prevention was all about and what I could accomplish. I accepted the position but needed to discover — or create — an approach through which I could have a deeper impact.
Shortly after I started my new job, a prominent local entrepreneur suffered a major heart attack. Ordinarily, he would have gone to a fancy private hospital, but he had his heart attack right across the street from the public hospital. Although the initial prognosis was poor, the excellent care resulted in a quick and near-complete recovery. This led to the county board of supervisors extolling the virtues of their health care facilities and the quality treatment they dispensed. As their meeting was winding down, one elected official, who had a background as a school health educator, asked the director of health, “But what about prevention? Do we do anything for preventing heart attacks?”
This was a great question. The entrepreneur had garnered local fame for both his extraordinary business savvy and his demonstrated lack of prudence in taking care of himself; his personal motto was, “Rich food, big cigars, why walk?” And he was known for his intensely busy and stressful lifestyle. But the expectation of men was to be invincible. I was anxious to hear what my new boss, the director of health, would say. Perhaps it could help shape my understanding of prevention and of my job. Without missing a beat, the health director responded, “Prevention? Yes, of course. We’ve got brochures.” Holding up a stack of flyers titled “Staying Fit and Heart Healthy,” he exclaimed, “We have these!”
People need more than a piece of paper to change their habits. In that moment in 1980, it became clear to me that I could have a much more significant impact by helping people prevent illnesses and injuries in the first place — before they happened.
Q: APHA is a long-time partner of Prevention Institute. As APHA strives toward our strategic goal of creating the healthiest nation, how can a prevention approach lead to new ways of thinking about how to reach this goal?
We know that prevention works. We understand that health matters to everyone, but some communities have been systematically disadvantaged and affected more than others, and it’s time to build that into a system that advances prevention and equity. We understand that our bodies, our minds, and our environments need to be aligned for health. We can’t talk about asthma and ignore housing and traffic; it’s not just about getting individuals to adjust, but about ensuring safe housing and improved air quality. We can’t talk about high utilization and ignore mental health and trauma — and it’s not just about identifying individuals with adverse childhood experience but about transforming adverse community environments into healthier ones that promote resilience. It is time not only to recognize the importance of community well-being, but to fully engage and align with community. This means partnering far beyond health organizations and achieving new strategies. It means ensuring our policies and practices move our norms and environments. APHA plays a critical role in enabling new thinking and solutions to be shared, and their methodology understood. More importantly, APHA is a partner and a leader in promoting policy and practice changes across the country.
We must never stop taking on what seems to be impossible. Major policy victories that required people to change unhealthy habits over time are now often referred to as easy victories — such as tobacco control, vehicle safety restraints and reducing drunk driving. These were, in fact, hard-won battles that took many years of intense work. Profound change is never easy, and some effective change right now may feel impossible, but it’s guaranteed when we engage together.