Richard Eckersley, director, Australia 21 Ltd (formerly at the National
Centre for Epidemiology and Population Health, ANU).
A colleague once
caught me helping myself to some cakes left over from a staff party. Getting
your fix of fats and sugars, she quipped. Yep, I replied, I was rebelling
against public health fascism. I had in mind the growing number, and sometimes
authoritarian tone, of health messages telling us how we should live. Hell,
even sitting down (for too long) harms health these days.
So [Crikey Canberra correspondent] Bernard Keane’s
attack on the ‘preventive health industry’ is understandable and partly right,
but for the wrong reasons. It’s not that the health messages are unwarranted:
There are real concerns about trends in both physical and mental health,
especially among young people (http://blogs.crikey.com.au/croakey/2011/04/22/challenging-accepted-wisdoms-about-young-peoples-health-and-wellbeing/).
But there is a
public or preventive health ‘industry’ in the sense of a professional body that
applies a specialised, and restricted, view of how to improve people’s health.
You can, as Keane does, talk of ‘social elites anxious to impose control on what
they disapprove of’, but it is not particularly helpful.
The ‘industry’ emphasises
modifying individual risk factors and lifestyles, particularly tobacco use,
poor diet and lack of physical activity, and harmful alcohol use (http://blogs.crikey.com.au/croakey/2011/04/06/challenging-mainstream-thinking-about-health-and-medicine/).
It largely overlooks the broader perspective of the social determinants of
health (broadly defined to include social, cultural, economic and environmental
factors). In doing this, it downplays the political or ideological significance
of sickness and ill-health.
As we learn
more about health, the bar of healthy living keeps getting raised - at the same
time as the weight of unhealthy cultural expectations, or pressures, keeps
increasing. Something has to give, and one result is the frustration and
resentment expressed in Keane’s articles.
In
promoting individual behavioural change, the orthodox public health approach
misses the crucial point that social conditions act on population health in
ways that cannot be reduced to individual choices. As British epidemiologist
Geoffrey Rose observed, there is a relation between the mean of a
characteristic in a population (for example, blood pressure or depressive
symptoms) and the prevalence of the related disorder. ‘(T)he deviants are
simply the tail of the population’s own distribution; they belong to each
other…’ Or, as he also said, ‘The visible part of the iceberg (prevalence) is a
function of its total mass (the population average)’.
This relationship
shows that disease and disorder are the result of social conditions, not just
individual lifestyles. Rose also argued that causes of cases can differ from
causes of incidence: that is, explanations of why an individual becomes ill can
differ from the explanations of why rates of illness in a population rise or
fall. Efforts to improve health must match, or be appropriate to, the scale or
level at which we seek improvement.
The two
approaches – individual and social - are not completely separate and distinct;
they represent the ends of a spectrum of interventions. Public health programs,
while they are directed at individual behaviour, aim to produce changes in the
population as a whole. They range from public education to substantial
legislative and regulatory changes to promote healthier living. And it can be
argued that social conditions are addressed elsewhere in government: through
taxation, welfare, consumer safety and environmental protection, for example.
However,
individual and population perspectives are conceptually different in important
respects, and the effects of social conditions on population health need to be better
understood and acknowledged as a basis for improving public policy and national
goals and priorities.
It is very
difficult for us to make healthy choices when the social conditions encourage
unhealthy preferences. It puts us under considerable stress. As Keane
demonstrates, we can respond angrily to attempts by governments and others to
interfere in our private lives and to tell us how to live (which is ironic
given a vast media-marketing complex spends billions of dollars doing just
that, with little opposition).
Industry
research on the recommendations of Australia’s National Preventative Health
Taskforce (which include tax increases and advertising bans) found more than
half of Australians reacted negatively, including agreeing that its report was
a political document ‘intent on overturning much of the way we choose to live’.
Richard Wilkinson, co-author of the influential 2009 book, The Spirit Level: Why Equality is Better for
Everyone, once
told me that people can't keep to good intentions about healthy eating,
giving up smoking and taking exercise unless they feel on top of life. ‘When we
feel unappreciated, stressed and (with) no way out, we are more likely to eat
for comfort and resort to alcohol, drugs, tobacco, and to become more
sedentary.’
Wilkinson and
others focus on the harm to health of inequality. I’ve emphasised the role of
culture, arguing that modern Western culture, with its growing psychological
stresses and pressures and its focus on consumption, pleasure and other
external trappings of ‘the good life’, is a health hazard.
I’ve
sometimes illustrated the importance of the social determinants of health by
telling ‘the parable of the drowned’, modelled loosely on Hurricane Katrina’s
devastation of New Orleans in 2005. Let’s assume most of those who perished
drowned. On this basis, the response (reflecting the individual focus of public
health campaigns) might be to issue life jackets, or to teach everyone to swim.
Going
further, we find that most of the losses occurred in low-lying parts of the
city, so the response might be not to build there. We then learn people lived
there because they were poor and could not afford to live anywhere else, so
poverty needs to be addressed. Then there were problems with the construction
of the city’s storm and flood levees and the filling in of coastal wetlands
that used to buffer storm surges, raising more questions about governance and
city development.
But none of
these explanations acknowledges the fundamental cause of the deaths as the
hurricane’s severity, and the role of climate change in increasing the
probability of such extreme weather events. This implicates industrial civilization.
The parable makes clear that understanding and addressing health problems at
the level of individual causes of death and disease are very different from
understanding and addressing the social causes of a population’s health. As with
climate change, so it is with social change.
This wider social perspective tends falls between stools. Public
health pays too much attention to the individual; political commentators and
analysts have too much regard for political theatre and policy detail. Both perspectives
are too restricted. Both need to consider in greater depth the ways in which our
world view - the whole framework of our way of life - works against better health
and higher wellbeing.
Citation/original
source
Eckersley, R. 2012. On Bernard
Keane, Public Health and the Neglect of Social Determinants, Croakey, 16 December.
Further reading
(available at www.richardeckersley.com.au
):
Eckersley R. 2012. Whatever Happened to Western
Civilization? The Cultural Crisis, 20 Years Later. The Futurist, Nov-Dec, pp.
16-22.
Eckersley, R. 2012. The
science and politics of population health: giving health a greater role in
public policy. Canberra: Australia 21 Ltd.
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