Introduction

In this chapter the aim is to explore in greater depth the idea of primary prevention in health, often referred to as ‘upstream’ action. In the context of health, the idea of prevention is complicated by the different ways of conceptualising health. The key focus of upstream interventions to promote health in later life is on the gap between life expectancy and healthy life expectancy. The idea of the compression of morbidity has generated a plethora of studies designed to identify more accurately appropriate interventions that will delay the onset, or at least the progression, of disease so as to maximise functional health. Interventions to prevent disease are of interest for economic as well as health reasons. In their report published by the World Bank, Adeyi et al (2007) comment:

We can infer from this that it is individual productivity that matters, as well as individual health.

Evidence of the wide range of determinants of health has also influenced lifecourse perspectives in epidemiology and there is increasing interest in public health in the interactions between different upstream factors, including social and environmental as well as genetic and physiological factors. Better understanding of the interactions between these can inform action to prevent disease in later life (Kuh and Ben-Shlomo 2004).

However, prevention also encompasses a range of ‘upstream’ measures that are about the maximisation of good health rather than merely the prevention of disease. Salutogenic perspectives on health in old age can be seen as a riposte to negative perceptions of ageing as being all about loss, decline and death. The salutogenic concept of health, reflected in the often-quoted adage ‘adding life to years not merely years to life’, is an approach that has wide appeal and is reflected in the ideas of ‘positive’ and ‘active’ ageing. However, in common with other public health concepts, these ideas are open to question and some of the criticisms that have emerged reflect the points raised in the previous chapter concerning the policy process and the creation of shared meaning.