what primary prevention will be like 25 years from now

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The Journal of Primary Prevention [jpp] HS117-228588 October 31, 2000 17:15 Style file version Nov. 19th, 1999

The Journal of Primary Prevention, Vol. 21, No. 3, 2001

What Primary Prevention Will Be Like25 Years from Now

Joseph A. Durlak1,2

In deference to Martin Luther King and Sigmund Freud, I had a dream lastnight. It was 25 years in the future and the United States had been transformedinto a prevention-oriented society. Here is some of what I saw.

Prevention training was required in all the service-related professions. Allnew graduates in disciplines such as medicine, education, and mental health werebeginning their professional careers knowledgeable about prevention, competent inoffering preventive services, and with strong personal values favoring prevention.Schools were fighting for applicants who wanted to learn prevention and offeringspecial fellowships and funding to attract the best students. Job announcementshighlighted openings for prevention specialists, and newly-hired workers joinedothers who were turning their organizations from stodgy bureaucracies into pro-gressive, innovative and caring institutions. Most mental health programs werenow really about health instead of problems and pathologies.

Substantial progress had been made in many areas of prevention between 2000and 2025. Things were not perfect, but they were so much better. For instance, thenumber of young children with inadequate reading skills had dropped from 70%to 20%, and twice as many students were displaying above average skills. Lessthan 5% of all students dropped out before high school graduation; school work-study and vocational programs supported by local businesses and industry werescrambling to interest young people in the trades, arts, and special occupations. Itwas now very easy to find a skilled craftsperson (many were women) to repair ourtechnology-filled environments.

The percentage of high school seniors who smoked regularly had droppedfrom 22% to only 5%, who drank alcohol to excess had plummeted from 31%to 8%, and who took any illicit drugs went from 41% to 11%. There were onlythree infants infected with HIV at birth in 2025, compared to an estimated 2,000 a1Department of Psychology, Loyola University.2Address correspondence to Joseph Durlak, Department of Psychology, Loyola University, 6525 NorthSheridan Road, Chicago, Illinois 60626.

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year at the end of the 20th century. The number of unwanted teenage pregnancieshad sunk below 100,000 from its high of over 1 million. Comprehensive healtheducation cut the rate of sexually transmitted diseases among young people byover 20-fold, including HIV infections.

After cresting near 20% in 2000, epidemiologists were arguing whether only8% or 10% of young people suffered from a diagnosable clinical disorder. Theincidence of mental retardation among young children had dropped to less than0.5% from its historically steady rate of around 3%; the level of learning disabilitieshad been cut in half.

The richest country in the world had finally instituted universal health care forits citizens. Economists had eventually convinced national and state legislaturesthat in the long run good health care for all produced over $50 in lifetime benefits forevery dollar spent. Corresponding advances in public health insured that 95% of allwomen (instead of only 66% in 2000) received adequate prenatal care throughouttheir pregnancy. As a result, infants born prematurely, at low birth weight, or withserious complications during birth and delivery were only one-tenth as frequent.It was rare for pregnant women to smoke or consume alcohol.

Many more Americans were exercising regularly and keeping fit. Walkathonswere the rage. Communities were being redesigned as residents clamored for moresidewalks, jogging trails, and bike paths. It was actually illegal to use a personaltransportation device (see below) for less than a one-mile trip. The incidence ofchildhood obesity had dropped from 20% to less than 5%, and was steadily de-creasing among adults as more individuals were continuing the active lifestylesbegun in their youth. The food and restaurant industries were competing vigorouslyfor increased market share by preparing and presenting healthy foods. They wereassisted by the major drug companies who were discontinuing heavy production ofpsychotropic medications because of decreased demand. Every school lunch pro-gram in the country (compared to almost none in 2000) met the American DietaryAssociation’s recommended daily nutritional levels. Children actually liked theirschool food and there was little waste. Loss of a prized part of the school lunchmenu was the prime response cost measure used by schools, and was an effectiveway to help students learn better self-control. A majority in a recent Gallup pollcould not identify the following items correctly: battered-fried, pop tarts, super-rich ice cream, Big Mac, or french fries. Plus, most people thought “junk food”had something to do with recycling leftovers into animal feed. Some things neverchange: pizza was still everybody’s favorite food, but genetic advances had con-verted it into a major health supplement, often recommended for the few whoneeded a nutritional boost.

Throughout most school districts, serious forms of misconduct and violencehad ceased being a major concern for almost ten years. Schools had become truecommunities of learning; teachers had begun earning the respect and salary rewardsthey deserved, and students were willingly performing community service if they

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embarrassed themselves by skipping school, being tardy, or not finishing theirhomework. Computers really helped children learn, and many software companies’profits were fueled by the educationally relevant materials they had developed.Each of the over 500 wireless mass media dot com companies (no one used theterm,television, anymore) had developed sequential interactive “learning stations”for individuals of all ages. These “enhancement modules” were so popular thatreservations were necessary during peak use periods. A few old-timers still watchedMel Gibson and Julia Roberts movies despite snickering and gentle ribbing byyoung people. Several broadcasts had been canceled over two decades ago: “worldwide wrestling,” Jerry Springer-like talk shows, and the “When pets attack theirmasters” series. No one could remember why anyone ever watched such things inthe first place.

The physical redesign of personal transportation devices (these PTDs usedto be called cars) had reduced the incidence of vehicular crashes involving anytype of personal injury by 30-fold. It was now impossible to operate any PTDwhen the driver was physically impaired (by drugs, fatigue, medical problems,or emotional upset), and unless all the occupants had properly engaged ridingstations (i.e., highly advanced forms of old-style seat belts and car safety seats).Electronic monitors in homes had also drastically cut the frequency of uninten-tional injuries (formerly called “accidents”). Adults were automatically alertedto hazardous home features, and could also monitor any risky behavior of theirchildren at home or in the neighborhood.

Affordable and accessible day care was available as needed, and mostMPCCCs (i.e., multi purpose community coordinated centers) promoted posi-tive child development and family life. MPCCC staff were earning decent salaries(for once, more than local dogcatchers) and staff turnover was next to nothingcompared to 40% 25 years ago. Furthermore, most businesses had liberal familyleave and flex-time policies for their employees; almost all had some connectionto local MPCCCs whose fees were underwritten by the employer. Businesses hadlearned they could not attract workers without offering such benefits.

Although the divorce rate had only dropped to just under 20% from 40%previously, there was much less chronic marital discord and domestic violence.This was probably due to intensive training and support services available to allpartners before and at all times during their marriage. Lesbian and gay couples,whose unions were officially recognized in all jurisdictions, also benefited fromthese services. The term,child maltreatment, was obsolete and had been replacedwith “needs some assistance in raising a happy, well-functioning child.” Anotherprobable factor responsible for better interpersonal relationships was the existenceof empirically supported “healthy living” classes which were routine in all schools.These classes (which often involved parents, business people, and other communityresidents) created high levels of life satisfaction and psychological well-being,and seemed to consist of sophisticated refinements and advances bearing a faint

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resemblance to some ancient concepts such as self-efficacy, problem-solving, andconflict resolution skills.3

These things seemed too good to be true. But like in all really good dreams,the secret of how things happened was disclosed. I saw a closed door, opened it, andstepped into a room which was bright, airy, and seemed to be some sort of shrine ormemorial. The sunlight streaming into the room pointed me toward a small plaquehanging on the far wall which was the only item in the entire room. As I approachedthe plaque, I learned who was responsible for the remarkable progress made in25 years and how they had done it. The plaque bore a statement by Margaret Mead:“Never doubt that a small group of thoughtful committed citizens can change theworld. Indeed, it is the only thing that ever has.”

When my alarm woke me up, I realized that those working steadily andpatiently toward their goal of a healthier society had a major impact. Many peopledeserved credit. I smiled. It was the start of a beautiful day.

3Alas, progress was limited in some areas. Although athletes had long been the highest paid of allworkers, they only returned half their salaries to local charities. Moreover, the Chicago Cubs had stillnot gotten into another World Series, making it 80 years since their last appearance, and 117 yearssince they had last won the world championship. Cub fans were still chanting “Just wait until nextyear,” no doubt excited about their team’s starting lineup which featured four Ernie Banks clones andfour Sammy Sosa replicants. Unfortunately, the club had traded all its pitching for Michael Jordan, ahome-town favorite from another era, without realizing that his court savvy and jump shot were bettersuited for another sport. The Cubs’ manager, Richard Daley, concurrently serving his 24th consecutiveterm as Mayor of Chicago, declared: “We gotta do more prevention. If we could stop da udder guysfrom scoring all dem runs, we’d be a contender.” Yogi Berra, the world wide web nightly news anchor,agreed: “Everybody knows that pitching is 80% of the game, the other half is defense, and the rest ishitting.”

what primary prevention will be like 25 years from now

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