Why good health outcomes and social issues will always be entertwined
Delivering positive health outcomes is a wider social issue and not one that can be solved by doctors alone.
Words: Dr Roderick Mulgan
Rudolf Virchow had quite a life. He lived in 19th-century Prussia and proposed, among many other medical contributions, that diseases must ultimately be understood as changes in cells, which has been the foundation of pathology ever since. But he is as equally famous for gazing through the window as he is the microscope and recognizing that disease was shaped by the world in which the average person had to live.
Following a typhus epidemic (typhus comes from contaminated drinking water), he famously wrote: “If medicine is to fulfil her great task, then she must enter the political and social life. Do we not always find the diseases of the populace traceable to defects in society?”
The imperative is just as real today, and the issues are as intractable. Drinking water and reticulated electricity are essentially sorted, at least for the first world, but smoking, processed food, alcohol, personal stress and domestic violence are not. Public health experts refer to the concept as the “social determinants of health”, making the average doctor’s preoccupation with cholesterol look as useful as the deck chair arrangements on the Titanic.
Doctors are trained in drugs and diagnoses but are generally presented with pathologies embedded in the broader sweep of the patient’s life. That life is the product of the costs and incentives the world offers. We get excited about a new drug, but many medications would be irrelevant if well-known principles of living healthfully were universally attainable.
We no longer send children up chimneys or send hatters mad with mercury poisoning, but most of the time, people who fail to live the entire length of their potential lives succumb to a disease that arose from the life they lived, which may or may not be the life they chose. Cancer and premature heart disease — our two biggest killers — occur mainly from lifestyle, particularly smoking and poor diets, long before doctors get engaged. While genes — personal susceptibility to disease — are relevant, they only account for about a quarter of longevity potential, averaged across the population. Lifestyle matters the most.
Income has a lot to do with it. Richer nations are healthier, and the benefits are far more than simply being able to afford doctors and nurses. Being wealthy means being able to educate your population (particularly the women) so that, among other things, knowledge of good health practices will be widespread. It means treated sewerage, heated homes, transport, and reliable food supplies, particularly of the fresh type.
But the lesson does not just apply to the third world. It also applies here, as the benefits of the well-off world are not distributed evenly. Wealthier people are healthier people even within first-world countries. There is no tidy reason, but it is a universal observation that the factors undermining health cluster at the rough end of town.
Poor suburbs tend to have ready access to purveyors of alcohol and fried chicken, less so vegetables and gymnasiums. The winter power bill in a low-income household is likely to be a huge chunk of the budget and something to be saved on, if possible. Mindful walks after dinner are not very appealing if the streets aren’t safe. Stress levels are higher in low-income households, and so are smoking and drinking to excess, which are probably related phenomena.
The relationship between money and health can corrupt other observations. It is well known — though controversial — that some major studies have shown that drinking moderate amounts of red wine is healthful, particularly when drunk with a meal. Red wine is full of antioxidants, so the observation is plausible. However, drinking red wine in modest amounts, and serving it with dinner, is a middle-class sort of activity. The same people will eat vegetables, exercise and visit their GP for cervical smears. All the red wine habit is doing is marking a particular social cohort.
It could just as relevantly be claimed that the value of a person’s car correlates with health; it probably does, but that doesn’t mean one is causing the other. This insight resonates in a time when health systems, including New Zealand’s, are accused of bias on the ground that outcomes such as longevity are distributed unequally. That charge only sticks if effects such as longevity are within the remit of the health system. Getting your broken leg fixed and pushing your baby out safely undoubtedly are, but these issues — major ones before the modern era — no longer undermine longevity in the modern world. Nobody suggests these needs aren’t usually competently met.
The short point is that most of the factors driving differences in longevity or good health generally do not engage the health system. There is some engagement with the health system via preventative interventions that doctors control, such as treatment for elevated blood pressure. There is also some engagement via education campaigns. But campaigns are only a minor aspect of what the health system is charged with delivering, and important public health messages are well known anyway. Notwithstanding these considerations, the main drivers of different outcomes reflect how the world works.
Much health commentary, particularly the political type, is fond of pointing fingers and asserting that the system is responsible for unequal outcomes when the inequalities exist in the issues that were presented to the health system in the first place. In my view, this needs to be more widely acknowledged than it is.
The situation persists because the solutions fall within the remit of politics. Few people argue the march to restrict smoking has gone too far, though they did when bans on pub smoking were first mooted. Yet banning alcohol didn’t work in the 1930s, and nobody is keen to go that far again. Which lesson applies to regulating our sugar intake? Restrictions or taxes on sugar are the next field of battle between industry and public health, and the same conundrums of liberty versus health costs, inflamed by the self-interest of big food-makers, are lining up to be fought over.
But the problem is even more comprehensive than policies that are directly health-related. The whole spectrum of political decision-making is engaged. How much money should be spent on public facilities, what they should be, how much those on low incomes deserve their position and how much is circumstances beyond their control have been the stuff of political debate since ancient Athens, and consensus is elusive. In particular, the level of income the unemployed should get from the public purse is intensely controversial.
Multiple competing considerations bear on these questions, but this is where the most significant progress is possible. Tasking the health system with delivering the best health for everybody is charging it with something all the politics in the world has failed to do.