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Is prevention better than cure?

Most people would answer “yes”. It is better for people’s well-being to prevent a problem than to deal with it once it arrives. And it saves public money. Governments now try to implement prevention strategies across a wide range of social policies, including health and mental health, crime, and early childhood development.

But at the same time, there is agreement that most current approaches are problematic. Why?

One answer is that most prevention policies have not really been “upstream”, or dedicated to tackling the social causes of social problems. Thus, for instance, preventing crime has largely meant fortifying buildings, increased CCTV surveillance, and placing metal detectors in schools. Preventing ill health has meant statins and smoking cessation classes, not tackling the promotion of unhealthy foods by corporations. Early childhood interventions have meant policing families and parenting classes.

All these programmes can be useful, but they rely on downstream or midstream measures rather than tackling the more fundamental social causes of social problems in an unequal and consumption-led economy.

This leads to the second reason why current approaches to prevention are problematic: real preventive policies have been derailed by powerful forces, like professional and departmental interests within the welfare state and business lobbies. Managerial reforms in the NHS, for instance, have generated new systems of payment by results that – by favouring outputs that are easily measurable and attributable in the short term – weaken the system’s capacity to deliver upstream preventive health measures.

Corporations like Serco and G4S, which now run a swathe of social services from care homes to prisons and welfare-to-work programmes, respond to similar incentives – incentives that encourage short-term outputs and cherry-picking. Another lobby group comprises companies that produce harmful products, such as sugary and fatty foods, and which acts to head off public interest regulation.

Another reason that prevention efforts rarely succeed is that preventive policies infrequently extend to the economy. They used to – the policies of full employment and social insurance, for instance, were both upstream policies. But over the past three decades, neoliberal pressures have favoured short-term profits and undermined precautionary policy-making. Many social and environmental problems originate in the economy. For example, the Marmot Report on health inequalities recognises the damaging impact of insecure labour markets, poverty and transient communities. Climate change policies are opposed by free-market advocates and business lobbies throughout the Anglosphere. These pressures have cut the ground from beneath early action and prevention programmes.

To move upstream from cure or care to prevention means tackling the economy. A more collective, precautionary political economy could prioritise meeting needs and avoiding harm. One way would be to prioritise meeting needs and expanding capabilities as opposed to blindly exalting “consumer” sovereignty. Another would be to measure the social value of jobs to distinguish between what Adair Turner has called productive jobs (e.g. care workers) from unproductive jobs (e.g. hedge-fund managers). But this would entail confronting neoliberal ideas and the nest of interests and institutions that now sustains them.

About Ian Gough

Ian Gough

Ian Gough is Emeritus Professor at the University of Bath, Visiting Professor at the London School of Economics and a member of the Academy of Social Sciences, UK. His books include The Political Economy of the Welfare State; A Theory of Human Need; Insecurity and Welfare Regimes in Asia, Africa and Latin America; and Wellbeing in Developing Countries: From Theory to Research. Some of his essays are published in Global Capital, Human Needs and Social Policies. He is currently researching climate change, human wellbeing and social policy at the LSE, and studying jazz piano.

Ian Gough @ London School of Economics

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