By John Deanfield
Professor of Cardiology, University College London
Over the past century, life expectancy has increased at a pace once unimaginable. A child born today has more than a 50% chance of living beyond the age of 95. This success has exposed a fundamental challenge for health systems, as longer lives are increasingly accompanied by prolonged periods of ill health, placing sustained pressure on services and public finances. While people are living longer, they are not necessarily living as many of those years in good health.
Longer lives increasingly mean longer exposure to chronic disease. Cardiovascular disease, diabetes, obesity and dementia typically develop gradually over many years. Their progression is often silent, shaped by prolonged exposure to a small number of well-established risk factors. When disease finally becomes clinically apparent, patients have already experienced avoidable loss of health, while society faces escalating costs through higher healthcare spending, reduced productivity and greater long-term dependency.
Harm reduction as a prevention strategy
A continued emphasis on treating disease only once it becomes clinically manifest will inevitably place increasing strain on health systems. A more effective approach is to intervene earlier to reduce harm before the disease becomes established. In this context, harm reduction represents a necessary and evidence-based shift in prevention strategy. It is often misunderstood as a concession, when in fact it reflects a pragmatic approach to reducing risk in real-world populations through evidence-based interventions that can be applied at scale.
In cardiovascular health, the underlying logic is well established. Prolonged exposure to elevated cholesterol, high blood pressure, smoking and excess weight drives the development of disease. Reducing such exposure, even partially, lowers long-term risk. When applied early and at scale, relatively modest shifts can deliver substantial population benefit and reduce long-term pressure on health systems.
Obesity represents one of the fastest-growing threats to health systems worldwide. It substantially increases the risk of cardiovascular disease, type 2 diabetes, several cancers and disability in later life. Its impact, however, is not confined to older age. Obesity undermines health, functional capacity and productivity across the working lifespan, with significant implications for both healthcare demand and economic participation.
For many years, policy responses to obesity relied predominantly on lifestyle advice, with limited success at population level. While behavioural change remains essential, experience has shown that it is rarely sufficient on its own to alter long-term disease trajectories at scale. This has prompted a reassessment of how prevention is defined and delivered.
Recent advances in drug-based treatments, including GLP-1 receptor agonists, medicines originally developed for diabetes that also reduce appetite and body weight, represent an important development. These therapies have demonstrated that sustained weight loss can be achieved safely and, crucially, that this is accompanied by meaningful reductions in major cardiovascular events. Evidence from large-scale clinical trials suggests benefits that extend beyond weight reduction alone, pointing to effects on underlying biological pathways linked to ageing and chronic disease.
For policymakers, the central question is no longer whether such therapies are effective, but how to deploy them responsibly and strategically within health systems. Their value depends less on their existence than on how they are integrated into care pathways. They should not be framed as cosmetic or discretionary interventions, but embedded within structured prevention frameworks, targeted towards individuals at the highest lifetime risk, and supported by appropriate clinical oversight and behavioural support. Used in this way, they function as instruments of harm reduction at scale, rather than isolated therapeutic solutions.
Comparable harm-reduction principles have been explored in tobacco control, although policy responses vary across countries. The broader lesson is that reducing exposure to the most harmful risk factors can lower disease burden, even when ideal outcomes are not immediately achieved.
These examples illustrate a broader point. Harm reduction does not replace prevention. It provides a practical way to reduce risk by lowering cumulative exposure to key risk factors over time, even when ideal outcomes are not immediately achievable.
Applying harm reduction in smaller health systems
In a health system such as Cyprus’s, these considerations are particularly relevant. Smaller systems often benefit from closer coordination between primary care, specialist services and public health authorities, enabling more targeted and coherent prevention strategies. This creates an opportunity to introduce emerging therapies in a more coordinated way, with clear criteria for use, clinical follow-up and supporting behavioural measures.
Cyprus faces challenges common to many European countries. Smoking remains prevalent, obesity rates continue to rise, and cardiovascular disease remains a leading cause of mortality. These are not isolated problems. They share common biological drivers and respond to similar preventive interventions.
A personalised harm reduction approach allows health systems to move beyond short-term thresholds and towards managing lifetime risk. It enables earlier identification of individuals at higher risk, clearer communication of that risk, and the use of proportionate interventions that reduce harm in the present, rather than waiting for the disease to become established.
Social and economic impact
The economic case for earlier intervention is as compelling as the clinical one. Poor health among working-age populations reduces productivity, increases absenteeism and contributes to earlier exit from the workforce. Preventable chronic disease is therefore no longer only a matter for healthcare systems. It represents a growing constraint on national economic performance.
Investment in prevention should be considered in the same terms as investment in infrastructure or education. Its returns accrue over time, but they are substantial. Delaying the onset of chronic disease by even five to ten years can markedly improve quality of life while easing long-term pressure on public finances.
Societies have adapted to longer lives through financial planning, pensions and savings. A comparable shift is now required in how we plan for health across the life course, with greater emphasis on preserving function and capacity over time.
The scientific evidence supporting earlier intervention is increasingly strong, and the range of effective tools continues to expand. What also continues to grow, however, is the cost of delay, measured not only in healthcare expenditure, but in lost productivity, reduced quality of life and widening pressure on public finances.
Extending life was one of the major achievements of the last century. Ensuring that those additional years are lived in better health must now be this one's priority.
