An effective sustainable health system is hampered by the 'business' of illness

With an ageing and increasing population “maintaining the status quo” is not sustainable.

A more upstream and broader strategy is necessary and it is ironic that a clue to the approach required has emerged from a narrower focus on a specific organ - the heart.

And this is not just because a recent study indicates that 75 per cent of heart disease is associated with preventable risk factors.

Getting to the heart of the problem

With heart disease being the commonest cause of death and contributor to disability and hospitalisation, cardiac epidemiology is a logical priority for study. Through expatriate Professor Sir Michael Marmot’s research into the causal pathways to heart disease (the Whitehall Studies), the broader determinants of health were unearthed. The importance of this work was recognised by the European Office of the World Health Organisation who approached and asked Professor Michael and his team from the International Centre for Health and Society to identify the broad implications for policy in ten selected areas.

The resultant booklet, The Solid Facts (pdf, 3.1MB), is currently being translated into the main European languages and is being distributed across health organisation networks in more than 25 European countries.

Of the ten steps Professor Sir Michael indicated that he would give priority to the first, namely social gradient. With my child-health bias, I admit to some disappointment when Sir Michael did not choose the early years as most important. On reflection, however, having parents who sense they are in control of their destiny is likely to induce a healthy psycho-socio-economic environment for raising a healthy child. His document and associated book refer to studies that demonstrate that poor social and economic circumstances present the greatest threat to a child’s growth, and launch the child on a low social and educational trajectory.

These threats to child health and development prompted a call for, “…a strengthened prevention agenda that extends beyond the capacity of the individually orientated medical care and require[s] a more vigorous and creative public health approach.”

There is now a wealth of evidence to guide the development of this public health approach both from overseas and in WA but a dearth of research to demonstrate the cost-effectiveness of early childhood intervention programs in the long term. However, the same applies to more costly interventions later in life making cost benefit comparisons difficult. The following table summarises the cost-benefit analysis of the highly acclaimed High/Scope Perry Preschool Program.

In this study, children were randomised to intervention and control groups and followed through until age 27. Although the sample was small (117) there was enough information to calculate cost savings from reduced time in special education programs, reduced need to repeat a grade and reduced chance of incarceration. Despite these calculations the Perry program is considered too expensive to implement universally. It would be revealing to compare the cost/benefit of this program with, for example, coronary bypass surgery. It is likely that the more expensive intervention (surgery) provides less return in terms of dollars saved. It is mere speculation that an early childhood intervention program might also prevent the need for cardiac surgery due to greater opportunity for reaching a higher socio-economic status. However, there is evidence that the foundations of adult health, including cardiovascular health, are laid in prenatal life and early childhood.

The illustration below shows the relationship between expenditures on programs in respect to learning, behaviour problems and health throughout the life cycle against expenditures during the critical years of brain development. By comparing the allocation of health and social service resources to adults in contrast to children it could be argued that the greater expenditure towards the latter end of life is driven by an inadequate investment in early life programs.