'We ain’t seen nothin’ yet'

Leonard Syme, Professor Emeritus of Epidemiology University of California, Berkeley” has said, “If we think our medical-care system is in trouble now, we ain't seen nothin' yet”. One of his suggested solutions is to develop better proactive strategies for preventing disease and promoting health, rather than waiting to fix problems after they occur.

This is a reminder of Joseph Mulins’ poem regarding The Ambulance in the Valley with its message that has been largely ignored for the last 111 years. While it would be folly to dispense with “the ambulance down in the valley”, it is also nonsensical to build additional hospitals or reorganise them “in the valley” in the hope it will address the increasing flow of patients - otherwise known as frequent flyers - hurtling over the cliff.

A double blind, randomised, placebo controlled, crossover trial is not required to prove that they would benefit from parachutes, but while this prevention strategy is worthwhile, it does not address the fact people need to be prevented from falling (or being pushed) over the cliff in the first place. A prevention fence not only needs to be built but it needs to be constructed in such a way it takes account of past flawed designs.

Professor Syme describes his experience with failed prevention efforts while Raphael claims that the focus on lifestyles and behaviour change is ineffective, particularly for those at greatest risk. In addition, these strategies “… divert public and governmental attention away from addressing the broader societal determinants of health”.

A study published in the British Medial Journal has added further weight to the evidence that adverse life conditions - not lifestyle choices - are the main contributors to obesity, heart disease and diabetes.

In the UK Wanless Report (pdf file 137KB)it was noted that public health interventions may have different effects on different groups in society, due to their levels of knowledge or their resources. Some groups may be more responsive than others. This in turn means that some public health programs may improve general health, but also increase the gap between the health of the better off and the worse off.

This may also be true of health care interventions that may have differential take up by different social class groups. Existing socio-economic inequalities contribute to further health inequalities; and also contribute to establishing social norms that reduce the demand for healthy goods and services, hence providing little incentive to supply the local market directly.

A Lancet editorial referred to the “catastrophic” failure of public health to prevent contemporary threats to health as demonstrated by the unabated increase in obesity across industrialised nations. An Australian response to the challenging Lancet article precipitated some suggestions including the establishment of a Ministry of Public Health. However, as Wilson & McGeorge point out, a new ministry runs the risk of becoming yet another compartment within an existing non-integrated health care system.

So how should an effective fence be built? The first step in its design should be to analyse the factors responsible for determining the health of populations. These factors have only comparatively recently been identified. A good overview can be found in Canada where they have been exploring these fundamental and complex issues for longer than anywhere else in the world. The crux of the matter is summarised in one of the many wise quotes of the late Dr Geoffrey Rose: “The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social.”

Wilkinson and Marmot have provided ample evidence to support Rose’s assertion in their WHO publication, The Solid Facts (pdf file 474KB) and these facts have been a major influence on one of the few publications in Australia that refer to health inequalities.

So what’s the obvious remedy? “It’s the economy stupid!” Strong economic growth is perceived as the panacea for all societal ills. There has been sustained economic growth in most developed countries for decades, so is there evidence of a benefit to health? As health systems are concerned with the opposite (factors that have a detrimental effect on health) it is difficult to find much work on the primary determinants of disease.

There is, however, an Index of Social Health, developed by Fordham’s Institute for Innovation in Social Policy in the United States that combined federal government statistics: including infant mortality; child abuse; unemployment; average weekly wages; health care costs; youth suicide; high school completion; teenage births; violent crime; and affordable housing. They compared each annual measure with the year in which it was at its best level. In 1973 the Index stood at 77 points; by 1994 it reached its lowest level at 37. 

Table 1

There appears to be a cost attached to the increase in Gross Domestic Product (GDP), and it is the most vulnerable who suffer the most, as indicated by the late Marc Miringoff, Director of the Fordham Institute Index who said, “the decline in the social health of children and youth tells us something about the future shape of our society”.

This apparent anomalous inverse relationship between GDP and social health has been described by Keating and Hertzman as modernity’s paradox. Smith & Rutter (Psychosocial social disorders in young people: time trends and their causes, 1995) also found evidence of increasing problems in their comprehensive analysis of the psychosocial health of children and adolescents and reasons for the increasing “social toxicity” have been suggested.

Under these circumstances it is not surprising that they recommended that those who are responsible for assessing progress should shift the emphasis from economic to social indicators.

Another reason for developing non-economic indicators is that the GDP and other economic measures are inadequate measures of progress. Two hundred years ago Scottish economist Adam Smith said, “The ultimate test of an economy is the wellbeing of its people”. This rationale for a robust economy seems to have been forgotten as Robert Kennedy pointed out nearly 40 years ago:

The gross national product does not allow for the health of our children or the quality of their education nor the joy of their play. It does not include the beauty of our poetry nor the strength of our marriages, the intelligence of our public debate or the integrity of public officials. It measures neither our wit nor our courage, neither our wisdom nor our learning, neither our compassion nor our devotion to our country. It measures everything in short, except that which makes life worth while.

The pursuit of economic growth as a remedy for societal ills would seem to be not only counterproductive from a health viewpoint but the strategy is being questioned from other perspectives.

The OECD High Level Advisory Group on the environment predicts, “Over the coming decades, economic growth will not be sustainable without serious attention to related environmental and social issues”.

Ayres (1996) has said:

The evidence is growing that economic growth (such as it is) in the Western world today is benefiting only the richest people alive now, at the expense of nearly everybody else, especially the poor in this and the future generations.

The United Nations Development Program has stated:

Human advance is conditioned by our perception of progress… it is time to end (the mismeasure of human progress by economic growth alone). The paradigm shift in favour of sustainable human development is still in the making. But more and more policy makers in many countries are reaching the unavoidable conclusion that, to be valuable and legitimate, development progress - both nationally and internationally - must be people centred, equitably distributed, and environmentally and socially sustainable.

The solutions

There are several clues provided in the deliberations above on how a fence should be built and who should build it - but there are also several obstacles.

Those responsible for treating the casualties in the valley can hardly be expected to also have expertise in fence building. And the fence builders cannot rely on resources being allocated from down in the valley: because the clinical imperative will always win the argument. And yet this is exactly how health systems are organised in most countries.

Don Berwick, CEO of the Institute for Healthcare Improvement has said “every system is perfectly designed to achieve the results it gets”. The focus of ambulances, hospitals and “health” departments is to save lives, and treat people with disease and injury - they are not designed to enhance the health of the general population or even “at risk” communities.

The Royal Australasian College of Physicians recognised that “health departments, by themselves, have little control over the underlying determinants of social and economic disadvantage” and they made recommendations to address the situation that have yet to be implemented.

One of the reasons that may account for the lack of progress in building the fence is the missing ingredient that Professor Syme realised during his challenging career. He advised that:

… to carry out those strategies successfully, we will have to work with the community as an empowered partner, which ultimately means changing our public-health model at a fundamental level. We will have to change the way we classify disease, train a new generation of experts, change the way we organise and finance public health education and research, and deal with our arrogance. These are very difficult and humbling challenges, but I know we can meet them. We really have no choice.

But previous surveys have documented a substantial gap in the community's understanding and attitudes about public health however, when people are well informed, they tend to emphasise that equity of access is an important criterion when making decisions on health care resource allocation. This is supported by evidence that justice is good for health.

In relation to community consultation, it appears that they are setting a good example for others to follow in Bayside (pdf file 155KB) but this will take time to emulate around the country. Meanwhile there is an imperative to act now as, sadly, it is children who are falling off the cliff more than adults. For the first time in history parents are predicted to outlive their children.

Rates of childhood obesity (pdf file 150KB) in Australia are at one of the highest among developed nations and rising at an annual rate of 1 per cent, a trend which suggests that half of all young Australians will be overweight by the year 2025.

While there has been much publicity surrounding the obesity issue, there is less awareness of the fact approximately one in four Australian children are vulnerable as a result of not reaching their full developmental potential at age five-years (pdf file 61KB). The implications of this on their future health and development have yet to be realised. More predictable is the prognosis for the one in five children who have a mental health problem.

When Professor Syme said, “we ain’t seen nothin’ yet” he was only referring to the fact that baby boomers with their multitudinous needs haven't even entered the older population yet. He was not factoring in the premature mortality among a relatively diminishing population that will need to be fit and healthy to deal with the burden of supporting the greying and demanding “me generation”. It is in the interests of the “me generation” to invest in their future guardians and it is in the interests of Australia to invest in children. In addition this makes economic sense and what better source than the comprehensive analysis by the World Bank to support this assertion with the latest evidence provided by Dr Fraser Mustard.

While there are measurable returns on early child development programs this will not convince those delivering “health” services in the valley, because the returns do not mature for years (pdf file 183KB) and because these programs go beyond preventing illness and injury to reducing, for example, crime, and drug and alcohol misuse (pdf file 145KB).

This is one of many reasons that Departments of Prevention need to be strategically placed, with funding ring-fenced, at the top (of the cliff). As it is a whole of government response to upstream prevention (pdf file 1.24MB) that is required, including the administration of health impact assessments. The responsibility for such a department should be at the very top i.e. the Department of the Prime Minister and Cabinet at the Australian government level and the Premiers’ Departments at state level.

This is the prevention fence that needs to be built. If all Australians are involved in a debate about its value and assist in its construction, there will be hope for success. Although the initial outlay will be high, "the best possible course is to safeguard the source", as the cost of not doing so will not only mean we need more ambulances in the valley, but also more jails, hospitals and rehabilitation centres.

It is at the top - together with the community as an empowered partner - that a vision should emanate to give young Australians a sense of hope for a healthier future that could otherwise elude them.