Primordial prevention targets the “causes of the causes” of ill-health and harm – the social and political determinants of health. In the US, these political and social environments are characterized by dramatic class-, gender-, and race-based inequalities in health, wealth, representation, agency, safety, rights, and opportunity.
To put primordial prevention in the right context, we must first appreciate that the negative, fundamental features of American society – its classism, capitalism, and institutionalized racism; its sophisticated mass media mechanisms of social control and corporate predation; unsustainable consumption and environmental degradation; its illegal drone assassinations, perpetual war for economic hegemony, and the growing domestic surveillance apparatus; unprecedented incarceration rates; and its deeply dysfunctional and corrupt political system that, while ostensibly a constitutional republic with democratic forms, operates as a de facto corporate oligarchy – all have significant consequences, either directly or indirectly, evenly or disparately, on the psychosocial and physical dimensions of health and well-being for society’s members. “The most effective prevention focuses on the weakest part of the web and not necessarily on the most proximal.”
Therefore, the greatest health benefits will come through strengthening schools, accessible child care, reducing unemployment and the guarantee of a livable minimum wage, organizing labor, stabilizing the economy to benefit the under-, working-, and middle-classes, restoring neighborhood infrastructures, reducing income inequality, reforming the legal system, reducing food insecurity, improving housing, investing in childhood, increasing public transportation, and so on. To take one concrete example of the effects of investments in health outside of the healthcare paradigm, let’s look at the idea of extending tuition-free public education in the US beyond k-12 to include higher education. Woolf et al. estimate that college education is seven times more effective than all medical interventions at preventing death. How can this be? Because “education (and income) are elements of a complex web of interwoven social and economic conditions that exert health effects over a life-time.”
The pattern is obvious: changes that measurably improve the quality, safety, security, and social equity of people’s lives will also improve their health.