Crikey’s Canberra correspondent Bernard Keane recently lobbed a few grenades in the direction of the public health sector, with a particular focus on those working in alcohol control (see here and here).
Crikey subsequently published a response from Michael Thorn, chief executive of the Foundation for Alcohol Research and Education, and Professor Sandra Jones, director of the Centre for Health Initiatives at University of Wollongong, as well as from Greens Senator Dr Richard Di Natale.
In the article below, Richard Eckersley, a director of Australia 21 Ltd, argues that the type of frustrations expressed by Keane arise as the result of the public health sector’s overemphasis on individual behaviour.
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, Eckersley says.
On Bernard Keane, public health and the neglect of social determinants
Richard Eckersley writes:
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 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.
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’ emphasisesmodifying individual risk factors and lifestyles, particularly tobacco use, poor diet and lack of physical activity, and harmful alcohol use.
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, keep 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.
Hard to make healthy choices in an unhealthy environment
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 civilisation.
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.
• Richard Eckersley is a director of Australia 21 Ltd (formerly at the National Centre for Epidemiology and Population Health, ANU).