The Tragedy of Successful Prevention - You Only Realize When You Fall Sick...Or Perhaps Not Even Then

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I picked this up from Jason Kottke’s blog piece, which in turn referenced Hank Green’s blog, where he wrote about his own Bluesky tweet in Apr 2025, which looked at the issue of disease prevention from the perspective of “no one knows when they don’t die”, which I have turned on its head to say “you only realize when you fall sick”.

He said, “A tricky thing about modern society is that no one has any idea when they don’t die. Like, the number of lives saved by controlling air pollution in America is probably over 200,000 per year, but the number of people who think their life was saved by controlling air pollution is zero” and he then made a video of the same thought process.

This is precisely what I started Atmasvasth.com with, in its earlier avatar of Matka Medicine, 4 1/2 years ago in Dec 2020 with my post,  Understanding our Health Matkas…what we can control and what we can’t control in our quest to live long, healthy. I re-explored this in my post “Interdependence”, where I used the image below to show how our health is a function of so many factors, most not in our control.

In Interdependence, I wrote

The air we breathe, for example, is an important factor that determines our healthspan and lifespan. For the most part, this is not something you can control. Where you live, the policies of your Government, the behavior of the people around you, all determine the quality of the air you breathe, showing us how the interdependence plays out across these circles. You may change your residence in the same city or change the city or even the country that you live in, or improve the air quality in your house or work-place, or shift to a higher floor, or wear masks, but in the end, when you are out in the open, you will still breathe the same air that others around you breathe. Whoever you are, you cannot escape the consequences of being in that same polluted air, whatever you do.

It is the same with the water you drink and the sewage you produce. Unless you live in a co-operative society that believes that everyone should have access to the same, safe drinking water and that all sewage should be treated equally, the quality of your health will depend then on which particular strata of that society you are a part of. If you live in a slum, where the sewage goes into a local canal that is uncovered and is next to your house or where the drinking water mixes with the sewage, you will never be as healthy as someone who drinks cleaner water and has a functioning separate toilet, where the effluence goes into covered pipes. 

So those who never fall sick because of the air they breathe, the water they drink and the sewage they produce, will never realize they are not sick because of these factors.

A month later, in Jan 2021, I wrote two back to back pieces about why all of us as a society are living long, healthy, starting with “The Matka of Better Life Expectancy” and then “Why We Live Longer and Better.”

In the second piece, I put up a picture of the pyramid of factors that affect our health, modified from the one Dr. Tom Frieden had created.

We don’t notice being healthy because we and those around us are gradually becoming more and more prosperous, which means, clean water, access to sanitation, availability of nutritious food and a roof over our heads. We also don’t typically realize lives saved because of seatbelt rules or smoking bans…we may crib when these laws are deployed the first time, but unless there is a specific incident involving these issues, we don’t really realize the years we’ve gained from stopping smoking or wearing seatbelts or using cars with airbags and other safety features. 

Last week, a member in my family landed up with herpes zoster. Despite crying from the roof about adult vaccination with an update just last month, we still hadn’t got ourselves vaccinated for herpes zoster, procrastinating and waiting for an opportune time. Every vaccine that prevents disease is typically never remembered, it is only when you get the disease, that you realize the importance of having been vaccinated in the first place…the pain that shingles gives you is something you will never forget. 

In India, childhood vaccination, though theoretically a tier III intervention that needs permission, is pretty much a tier II act where it is practically considered mandatory. Though specific Indian data is not available, 154 million deaths have likely been averted worldwide due to vaccination since 1974 [1], which includes 146 million among children under 5 years of age, of whom 101 were infants under 1 year of age. For every death averted, 66 years of full health have been gained on average. A large number of these are likely to be Indians, given our population and a > 90% coverage in 2019 of the Universal Immunization Program.

This is a result of Government laws, easier access to vaccines, the work done by social workers and healthcare workers and society leaders urging people to get their children vaccinated, a typically invisible combination of tier II and tier III consequences.

You know the importance of this only if you fall sick from diseases that are preventable by vaccination, otherwise you will never know, because all this has been taken care of, for you.

It is important to realize that doctors, hospitals and the healthcare system are per se responsible for just a small part of our health and yet the resources allocated to them far outstrip the resources that should be reserved for tier I-III strategies, simply because we can measure what we see…disease, but are unable to understand and see…absence of disease.

Most of our health is a function of where we live, when we live, our exposure to pollution (air, heat, cold), the laws of the land and mandatory processes. Finding a disease as part of prevention comes later…it is more important to prevent the disease in the first place. For example, if mammography picks up a breast cancer, the modality and the doctors get credit, but if 10 women didn’t get breast cancer in the first place because of a healthier living environment, no one would get credit because you never would think about a problem that didn’t occur in the first place.

Give this a thought!! You only realize you are healthy, when you are no longer so and fall sick...and you may never realize what keeps you healthy, perhaps even after you have fallen sick and recovered.

Footnotes

1. Shattock AJ et al. Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization. Lancet. 2024 May 25;403(10441):2307-2316. doi: 10.1016/S0140-6736(24)00850-X.