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

By Bret Hart - posted Monday, 10 May 2004


Clearly, investing in early childhood would be a very long-term solution to the current illness crisis - and there is only circumstantial evidence to support this theory. But even if the theory proves to be wrong the benefits from investing in early-childhood programs would be inestimable. And that’s the problem. In a market economy, if the value of a product is immeasurable there is a little chance of attracting investment especially as children are non-contributors to the GDP. A similar disadvantage applies to “health” for which there is no demand - only for its return when it has been lost.

Mathers and Douglas summarise the situation in Eckersley’s book Measuring Progress by saying:

In the modern economic climate, outcome indicators are seen as measures of productivity and they are inclined to influence what services do. While there are well validated indicators of death, disease, and disability, the systematic measurement of the impact of disease on wellbeing is still not well done, a measurement of the positive constructs of physical, mental, social and spiritual well being is not generally seen as an aspect of health sector activity.

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This one-sided view of health also ignores what has been learnt about the broader social determinants of disease and the two-way connections between wellbeing and illness. The psyche is intimately connected to the soma; nearly every disease is more common or more serious in the socially deprived, and the way individuals in society deal with disease is intimately linked spiritually … Whatever the recent gains of medical technology, immunology and molecular biology, in changing the course of illness, there must be said in the context that huge gains in life expectancy were well under way before the advent of modern medicine and that the social environment seems to be a major factor influencing not only illness but also well being.

In the 21st century it will simply not be adequate for health systems to continue to focus exclusively on illness and on prolongation of life ... Failure to properly conceptualise and measure positive wellbeing and sustainability may be contributing to the myth of a community’s aggregate wealth is synonymous with its wellbeing. That premise could be utterly false.

The medical fraternity has benefited from and continued to build on the illness business that our primeval practitioner established millennia ago. The time is overdue for us to recognise we have contributed to the problem and we are, therefore, part of the solution. Perhaps the inverse of the prevention paradox is a factor - namely an intervention that brings large benefits to each participating individual but affords little to the community. For example, a patient may benefit from the latest diagnostic imaging technology - because the physician is better able to make a diagnosis - but if this comes at the cost of a universal prevention program that would benefit thousands of people, is this justified?

The community needs to be involved in a debate with medical practitioners on how much it is prepared to pay for treatments that have a limited impact on the health of the population.

The Health Administrative Review Committee noted that, within Western Australia, some work has been developed by the Medical Council to work with Citizens’ Juries about priorities in health. The Committee recommended that the Minister for Health and Health Department initiate a continuing, informed, bipartisan community discussion as to what Western Australians can expect from their health system, and the priority issues to be addressed.

During this discussion it would be prudent to take note of a suggestion by the US Committee on Integrating the Science of Early Childhood Development:

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The charge to society is to blend the scepticism of a scientist, the passion of an advocate, the pragmatism of a policy maker, the creativity of a practitioner, and the devotion of a parent – and to use existing knowledge to ensure both a decent quality of life for all of our children and a promising future for the nation.

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Article edited by Fiona Armstrong.
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About the Author

Dr Bret Hart a public health physician practicing in Western Australia.

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