The international heavyweight of a social understanding of health, Sir Michael Marmot (who, ironically enough, also wears the cap of British Medical Association president), is currently visiting Australia for a World Medical Association meeting.
In this ABC interview, he argues that doctors should become more involved in tackling health inequalities. You can also hear him in much more depth from this podcast of an ANU lecture, or read his blog (it hasn’t been updated for a while, will be interested to see if he ends up writing about his observations of the state-of-play of Australian policy and the social determinants of health).
Meanwhile, on related themes, Richard Eckersley, has just published an article at WebmedCentral (for more on this novel approach to publishing, see bottom of the post), titled The science and politics of population health: giving health a greater role in public policy. An abbreviated version follows below.
Better health, not greater wealth, should be society’s goal
Richard Eckersley writes:
The rise in life expectancy, which more than doubled globally last century, is a cornerstone of human development. While there are competing theories about what produced the health gains, they can be, broadly speaking, attributed to factors such as material advances, especially better nutrition; public-health interventions such as sanitation; social modernisation, including education and social welfare; and improved medical treatment and care.
Historically, then, medicine and other health professions have been part of a broad, progressive movement that has improved not only life expectancy and health, but quality of life more broadly. The connection was close; the early emphasis in public health was on how social conditions influenced health and how they might be improved.
Today the relationship has changed. Health professions are increasingly engaged in countering the growing harm to health of adverse social trends, at least in developed nations. At the same time, however, they have become part of the problem because of a scientific emphasis on, and political advocacy of, a biomedical model of health based on individual cases of disease and their associated risk factors and treatments at the expense of a social model of disease prevention and health promotion. This has contributed to a separation of population health from social conditions, to the detriment of both.
Most public-health initiatives focus on individual risk factors associated with physical health: smoking, diet, exercise, alcohol use. From a health perspective, this emphasis neglects the importance of mental health; from a prevention perspective, it under-estimates the importance of social and environmental determinants.
Furthermore, the research on social determinants focuses on socio-economic factors, notably inequality, to the neglect of cultural factors such as excessive materialism and individualism. Culture and mental health are closely linked; both concern what people think and feel. This is seen clearly in young people’s health, an important predictor of future population health. Contrary to longer historic trends and official perceptions, young people’s health has arguably declined over recent generations in developed nations because of rising obesity and mental illness.
Acknowledging the importance of culture and mental health highlights the social significance of health in two ways: by casting doubt on orthodox thinking on human development and national progress, which places Western nations at the leading edge; and by showing health is an important social dynamic, a cause not just a consequence of how well society is faring because it affects people in all their roles – as citizens, workers, students and parents.
The dominant biomedical perspective suits business and government. It is in biomedicine that profits are to be made, not in social health. This model also limits the political significance of health to the politics of healthcare services. This policy focus is challenging enough as governments struggle with rising demand and costs. However, the challenge is easy compared with trying to reconcile emerging health-based social realities with existing wealth-based political priorities. Embedded in the biomedical model is a hidden ideology that defends and promotes the status quo.
The scientific and political responses to the situation might include more research on public and mental health, especially transdisciplinary approaches that integrate epidemiological, sociological, psychological and anthropological concepts and evidence. Similarly, with health services and programs, the share of the health budget allocated to public health and mental health should be increased.
The response also needs to go beyond the health system to embrace, for example, rethinking the role and purpose of education, and greater regulation and control of business, especially advertising and marketing, the dominant promoters of an unhealthy, hyper-consumer culture.
However, the most important application of this perspective may be in the contribution it can make to a much broader political and public debate about the lives people want to lead, the societies they want to live in, and the futures they want to create. That debate is intensifying, but health plays only a limited part in it.
A broad view of population health and wellbeing and their social drivers – socio-economic, cultural and environmental – challenges the legitimacy of the dominant worldview of material progress (which gives priority to economic growth and a rising standard of living), and supports the alternative, sustainable development (which seeks to balance social, environmental and economic priorities to achieve a high, equitable and lasting quality of life).
The contest between the two models, or narratives, of progress has been framed largely in economic and environmental terms, and the social dimension has been neglected. Population-health research can help to correct this distortion.
Medicine and other health professions might consider their purview is the provision of healthcare services. However, they have a powerful influence over the way society thinks about health, and acts on it; they provide the main reference points on health for government, media and public. It is time they reappraised more deeply the science and politics of population health; and it is appropriate that researchers, officials and practitioners in public health, with its emphasis on prevention and populations, take the lead in this task.
• Richard Eckersley is a director of Australia21 Ltd, an independent, non-profit research company and a visiting fellow at the Australian National University.
The full article is published at WebmedCentral, which is self-described as: “A unique portal for rapid and free dissemination of biomedical knowledge through Post Publication Peer Review”.
The article has had two postive reviews, including one from Dr Sandra Carlisle, a public health researcher at the University of Glasgow (as per below):
I have only favourable comments to make on this valuable paper, the publication of which I entirely endorse. Eckersley’s arguments about the need for population health approaches to be re-thought are cogently argued. He effectively challenges some of the dominant orthodoxies which actually hinder broader understandings of what creates and damages health and wellbeing, so this article needs to reach the public health community. He convincingly explains the relevance of mental health and illness to population health and the problems with current (socio-economic) conceptualisations of the social determinants of health. His explanation of how and why epidemiology currently fails to grasp the importance of ‘culture’ is particularly timely. Few in public health truly understand the distinction between social structure and culture, so the influence of the latter tends to be profoundly under-estimated. Importantly for an international readership, he explains the relevance of the contemporary ‘dis-eases’ of affluent Western societies to the developing world. He is to be congratulated, I believe, on this important and well-written paper.
“Embedded in the biomedical model is a hidden ideology that defends and promotes the status quo.”
Swap ‘biomedical’ for psycho-social-cultural (sometimes with a ‘bio-‘ hastily added in front of it for propaganda purposes), and the same holds true. The oft repeated assertion that this side of research and medicine does not get a hearing at the table is nonsense. For example, it holds a very powerful position in mainstream establishment medicine and government policy advice in the UK, and other places. Unfortunately, it is not clear it has delivered any good result yet, despite all the rosy promises, and indeed is probably causing more than a few nasty problems for innocent people. At a practical level this view seems to be mainly used to unjustifiably deny legitimate claims for public and private disability insurance.
“The dominant biomedical perspective suits business and government.”
Plenty of interest from business and government in the psycho-social-cultural stuff when it suits them, such as when it can save them a bit of money, or score them a few cheap political points, all off somebody else’s suffering of course, and with no justification.
At least biomedical interpretations are much more objectively assessable than psycho-social-cultural ones (especially when making specific diagnoses in an individual).
If we want to promote a societal shift towards seeing ‘health’ as broader than ‘medicine’ perhaps we should start using the word ‘illness’ instead of ‘health’ when talking about biomedical pathology. I wonder if the government Dept of Illness would lose some of its budget to the Health remits of the Depts of Education and Social Welfare.