"Every System Is Perfectly Designed to Achieve Exactly the Results It Gets." Don Berwick

Test of YouTube

“Perhaps the most perplexing and ambiguous issue in the study of health since its inception centuries or millennia ago, is its definition.” Sander Kelman A/Professor of Medical Economics, Cornell University.

Chapter 2 Management Madness

“So much of what we call management consists in making it difficult for people to work” Peter Drucker

Occasionally on a Saturday morning, I joined my father on the tube train for the half hour journey to Trafalgar Square tube station from where we walked the short distance to Charing Cross Hospital. Whilst he was busy in his office, I played on his secretary's typewriter in an empty office next door. A hatch linked an adjourning room through which he talked to the handful of his support staff. This was virtually the extent of the staff and infrastructure that administered a group of London based hospitals with my father having the quaint title of “House Governor” that lasted until his retirement in the early seventies.

It was at that time that a National Health Service (NHS) Reorganisation White Paper foreshadowed changes ahead and the house governor role was replaced by a more highly paid Chief Executive. From my observations as a medical graduate in 1972, this was the beginning of a growth industry in health services management driving multiple reorganisations that has spread around most industrialised countries at great cost but with questionable benefit.¹

The theories underpinning these changes suggested in the NHS reorganisation white paper did not inspire confidence. A review of the NHS White Paper² referred to the “garbage-can model of organisational choice” and the “muddling-through” approach to policy-making.

The original motivation for instigating the reorganisation is lost in the mists of time but from my recollection there was not a great deal wrong.  Despite the old adage, “if it ain't broke, don't fix it”, fixing happened in spades and has been happening ever since leading many health systems to head towards going broke. Even if there were problems, a massive exponentially enlarging sledgehammer was created to crack what was probably a small nut. Anecdotally, it was suggested that some doctors wielded too much power with some building empires and/or others believing that no expense should be spared for the best interests of the patient. Clearly that could not continue.

Whatever was the original motivation for change, once the reorganisation rollercoaster had begun, it could not stop because new Ministers of Health and Health Service managers have to instigate change because 'business as usual' would not justify voting in a new government Minister and/or appointing a new health chief.  So the shorter the tenure of the Minister and/or health chief (and they often go together) the greater the number of reorganisations.

With the prospect ahead of change for the worse, I could see the writing was on the wall for the NHS and this was one of the reasons for my exploration of other opportunities and health systems elsewhere. However, the changes instigated in the UK seemed to follow me to Canada and Australia – but a few years later. For example, ‘Medibank’ was introduced as a national health service within a year of my arrival in Australia and later changed to ‘Medicare’. The rationale touted at the time was that a minority of the population could not afford private health insurance and therefore did not have access to health care. I recall doctors and nurses saying at the time that no patients were turned away because of not being able to pay. I wrote a letter to the paper suggesting that rather than set up a whole new infrastructure why not use a Medibank levy to provide free health insurance to those unable to afford it. The letter was not published. It seemed that Australia was destined to create a completely new bureaucracy. To subsequently learn from an internal source that a senior Medicare staff member was being paid to do nothing was particularly frustrating at a time when health care service budgets were being pruned. Also exasperating was that by the time Australia began emulating a newly created model from overseas, they were starting to dismantle it in the original country after discovering flaws. I challenged an Australian health bureaucrat on this nonsensical approach and he replied, “Ah, but we have learnt from their mistakes and we will do a better job.”

One of the UK models Australia copied was to decentralise. Up until the late 70s in Western Australia, the department that managed the health system for the whole State was housed in a 10-story building. When the announcement was made to set up regional health authorities there was a reassurance given that they would not be clones of the original HQ in the regions.  Not only did this occur, but also staff had to move to larger headquarters in the CBD.

About the time of the start of these multiple organisational changes, a quotation ascribed to Gaius Petronius AD 66 circulated:

We trained hard but it seemed that every time we were beginning to form up into teams we would be reorganised. I was to learn later in life that we tend to meet any new situation by reorganising; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency, and demoralisation.

The earliest reference to this quote is in the nineteen seventies indicating that it was a concoction³ with its source a matter of debate.⁴ False or not, its widespread dissemination throughout health systems in most developed countries is evidence that it was meaningful to many. It fed into a growing cynicism amongst health service employees ⁵ prompting the need to develop a survival guide.

Following decentralisation there was the never-ending opportunity to decide that the subsequent health authorities, districts or regions were either too big or too small necessitating mergers or splits. Sure enough, this is what happened with consequences that were not only experienced in the UK but elsewhere. 7

Pamphlet Power

One of the most influential changes to the health system exported out of Britain arose out of a series of circumstances described in detail in Timmin's book, The Five Giants ⁷

A financial crisis in the mid 80s prompted yet another review of the NHS to explore new ways to fund it. The UK government explored the idea of a health stamp from which those who took private cover could opt out. However, the Prime Minister at that time, Margaret Thatcher, favoured tax breaks for private health insurance. However, the Chancellor of the Exchequer, Nigel Lawson, vigorously opposed tax breaks, arguing that they would produce "not so much a growth in private health care, but higher prices".

The Secretary of State for Social Security, John Moore, believed that allowing people to opt out would encourage the healthy and wealthy to take their money out of the NHS in return for private cover at low premiums. This would leave the NHS to cope with the most expensive business of treating children, the elderly and the chronically sick who stood no chance of acquiring cheap private cover. (This debate continues in various guises in different countries). Failing to agree, the leaders of the nation noticed a previously ignored pamphlet produced in 1985 by a visiting American academic who was advocating for a purchaser/provider split. In essence, the idea was to split health care management into two with one arm responsible for purchasing or commissioning of health care with the other arm managing the provision of health care services. Meanwhile, on top of the financial crisis at the time, the Presidents of the Royal Medical Colleges in December 1987 publicly announced the NHS had reached tipping point.

Beleaguered and battered by the crisis, Margaret Thatcher, without warning during a BBC Panorama interview in January 1988, announced that an NHS review was already under way thereby ensuring that her Civil Service would make it happen. Like most reviews and consultations, the outcome – to introduce market principles into health care - was predetermined. A year later a White Paper, Working for Patients set the framework for implementing the ₤600 million reform that precipitated the “...biggest explosion of political anger and professional fury in the history of the NHS.”⁸ Nevertheless the internal market idea caught on around the world and the impact can still be felt today with the modus operandi of most health systems being preoccupied with finance. Despite the Working for Patients rhetoric, the welfare of the patient seemed not to be the prime concern.

As expected, the novel idea of buying ‘health’ was imported to Australia and I recall the sales pitch from a bureaucrat, “if you can sell hamburgers profitably, you can sell healthcare in the same efficient way. Those who produce the best product will thrive.”

This approach was consistent with the latest fad of content-free management:

If you can manage a business that producers hamburgers you can manage a health service. It is not what the business does that counts but how well you manage it.

It is a pity that this analogy was not carried through to its ridiculous extreme. If you are going to sell a product, isn't the first step to conduct a market survey -  to find out if the product is likely to be popular - to determine if this is a product that the customer wants? However, in relation to healthcare, what is the product? Some say it is 'health' some say 'health care' some say 'health services' etc.

According to Tony Scott, of the Melbourne Institute of Applied Economic and Social Research, Melbourne University suggested that we do not know or measure what our product is:

To have a health care system that does not routinely measure patients’ health improvements, is akin to having a business that does not measure profit.  Failures (death rates) are measured very well, but success is not. ⁹

Is there any other multitrillion-dollar industry that is not sure clear what it produces? Perhaps if it had some shareholders it might be held to account.⁹

We are starting to get to the source of the problem. We have health systems consuming about a quarter to a third of government taxes with the only accurate measure of outcome being deaths related to failures of the system. Clearly, there is a long overdue need to determine the return from this vast expenditure. If a hamburger outlet produces hamburgers, shouldn't a health service produce health? If so, what is this product called “health.” This basic unanswered question warrants further exploration and we will do so in chapter 4. Meanwhile in this mini-chronology of health system changes, it is time to acknowledge the frustration and pain that these changes can induce.

Change is the only constant*

Perhaps it is a response to the powerlessness felt by those who are victims of the inexorable change juggernaut, that humour and allegory are used by several reviewers of the situation. For example, Professor Jeffrey Braithwaite and colleagues suggest that the motivation behind the architects of change must be that they get some self satisfaction from their activities:

Almost everyone does it. It is pleasurable for some, apparently and stressful for others—you only have to watch people at it. Others find it painful. A relatively small number are opposed to it, and will fight hard to stop it happening. But they are few, and most people simply grin and bear it.

More seriously, they identified the restructuring phenomenon spread across the UK, USA, Canada, Australia and New Zealand with variable consequences as summarised in the box.

In summary Braithwaite said:

The tectonic plates of organisational structures always seem to be moved around in healthcare but does this change the way clinicians practice or services get delivered? The evidence on balance suggests not. So it's a puzzle why ministers and senior departmental staff keep restructuring. Perhaps it's just an exercise of power more than anything else. ⁶

In his editorial comment on Braithwaite’s paper, Kamran Abbasi, said that the frustration for health professionals is that there is an increasing onus on them to ensure that their decisions are informed by the evidence whilst politicians develop health policy and health service reforms in an evidence vacuum.¹⁰

Taking a more light-hearted look at the phenomenon of health system management Oxman et al explored the reasons for the recurrent reorganisations and concluded that they included, “...money, revenge, money, elections, money, newly appointed leaders, money, unemployment, money, power-hunger, money, simple greed, money, boredom, and no apparent reason at all.”

Not so funny is that they estimated that trillions of dollars are spent on strategic and organisational planning activities each year, providing lots of good reasons for hundreds of thousands of people to get into the business. They surmised that new leaders were intoxicated with the prospect of change further fuelling perpetual cycles of what they feel is a more accurate description: “redisorganisation”. This was a term first coined by Smith, Walshe and Hunter in a editorial describing yet another reorganisation of the NHS involving “...unhappy managers that only worsen the service.” ¹³

Oxman and colleagues identified eight indicators of successful redisorganisations:

1. All the good people have left, or become catatonic
2. Inept people have been given tenure, or its equivalent
3. Important decisions have been postponed, or are being made on a whim-to-whim basis
4. Resolutions are being mistaken for solutions
5. The number of administrators has more than doubled
6. In healthcare redisorganizations, vast resources have been diverted from patient care, research and education and spent on relocating and refurnishing executives' offices and supplying them with the flashiest business machines
7. Administrators' office windows point toward, not away from, nearby mountains, lakes, and oceans
8. Large consultancy fees have been paid to relatives by blood or marriage

            Whilst this may appear ludicrous, it has been said that there is many a true word spoken in jest. A study from the UK’s National Audit Office of the reorganisation of central government revealed that in the four years up to 2009 there were more than 90 reorganisations of central government departments and agencies. The costs of 51 of these reorganisations for which data could be found were £780m, although the authors think this is a substantial underestimate of the true costs. They pointed out that the benefits of reorganisation were unclear, that the process was often poorly managed, and that its impact on performance was often adverse.  Despite this report quoted in a BMJ editorial, ¹⁴  in 2011 the UK is embarking on the “biggest upheaval of the NHS in its 63 year history, at breakneck speed, while simultaneously trying to make unprecedented financial savings.”  This plan, described as “mad”,¹⁵  was predicted to be the end of the NHS. ¹⁶  Walshe 9 appeals to the government to learn from three key lessons from the past as it embarks on what the Lancet ¹⁶ described as the catastrophic break up of the NHS:

1. Structural reorganisations don’t work. There is little evidence to show that the causes of poor performance are structural and past failures do not result from any particular structure but from these repeated reorganisations and the discontinuity and disruption they produce.
2. The transitional costs of large scale reorganisations are huge, although they are often discounted or ignored, and the intended or projected savings from abolishing or downsizing organisations are rarely realised. Closing down or merging organisations produces a round of expensive redundancies, early retirements, and redeployment, while new organisations find new premises and appoint lots of new staff. On the basis of the UK's National Audit Office’s survey data, Walshe estimates that the 2011/12 NHS reorganisation will cost between £2bn and £3bn to implement, at a time of unprecedented financial austerity. Reorganisations are often presented as an exercise in cutting bureaucracy and yet over the past two decades the numbers of managers and the management costs of the NHS have grown steadily, regardless of reorganisation.
3. Reorganisations can destabilise organisations or services and result in poor performance or failure whilst absorbing a massive amount of managerial and clinical time and effort. This distraction away from the core business of health services saps morale and creates uncertainty about the future. In addition, new or merged organisations take time to become established and start to perform well.

Again a natural response to this potentially alarming prospect for future health in the UK is to turn to humour and reflect on how it would be possible to end up with the ridiculous situation of the frantically busy hospital with no patients as depicted in an episode of Yes Minister. 12 Particularly apt was this exchange:

Jim Hacker: A hospital must produce results!
Sir Humphrey: Ha..ha, Minister!  We don’t measure our hospitals by results but by activity – and the activity is considerable and productive.

Activity Based Funding was introduced in the United States and in several European countries. In some instances it helped to reduce wait times, but in others it has substantially increased costs. In England, the British Medical Association has expressed profound concerns that ABF has fragmented care and undermined the public health care system by facilitating privatization of services. Despite these concerns, Australia introduced this approach as a major reform of the health system in 2010 - almost three decades after the authors of Yes Minister had suggested as a joke that hospitals are measured by activity not by their results.

Associate Professor Andrew Keegan also drew a similar conclusion nearly 30 years after the Yes Minister episode went to air in 1982, “We are incapable of measuring what we really need to know, and, even if we could, we are constrained by a system that probably could not respond.”¹⁷

The underlying problem is not so much that hospitals have no patients and health staff as depicted in the television program - but nobody runs them. This was the astounding conclusion of John Menadue after heading two health inquiries in NSW and South Australia.¹⁷

It is ironic that one of the outdoor scenes in the Yes Minister episode showed the then new Charing Cross hospital where I worked for my first year as a junior doctor. At that time, I knew who was running the place. It was the senior consultant and the matron advised by a hospital board with my father responsible for the administrative side – and they all knew their place, although on one occasion my father was motivated to step outside his assigned role.

My brother developed mumps encephalitis and when being admitted to hospital the doctor said that they had a similar case earlier and he had died. My mother was understandably upset prompting my father to write an article in the Observer entitled “Humanity in Hospitals” and this led to an interview on the BBC's Panorama program.  He was ostracised by many for daring to criticise the medical establishment but an editorial in the Postgraduate Medical Journal highlighted the fact that with the massive hospital rebuilding program in the 60s it should not be forgotten:

…that however attractive and efficient a hospital building may be, it is the kindness and understanding shown towards him that will matter to the individual patient...it is human relationships that matter most in the end. ¹⁸

It is no joke, that 35 years later, after all the energy and financial investment in health system reorganisations that it is not only unclear who is in charge but also uncertainty about what benefit there has been for the patient. Has humanity increased in the system? This is not being measured. It has been said, “if you cannot measure it, it doesn't exist”.

It is easy to measure whether a health service activity and whether it has come in on budget or not and this has become the predominant concern following years of expenditure on redisorganisations that could have been invested in activities and programs to prevent people becoming users of hospitals in the first place.

It seems that nobody has taken any notice of the message conveyed in the following poem composed by Joseph Malins in 1895

The Ambulance Down in the Valley

Twas a dangerous cliff, as they freely confessed,
Though to walk near its crest was so pleasant;
But over its terrible edge there had slipped
A duke, and full many a peasant.
The people said something would have to be done,
But their projects did not at all tally.
Some said, "Put a fence 'round the edge of the cliff,"
Some, "An ambulance down in the valley."

The lament of the crowd was profound and was loud,
As their hearts overflowed with their pity;
But the cry for the ambulance carried the day
As it spread through the neighbouring city.
A collection was made, to accumulate aid,
And the dwellers in highway and alley
Gave dollars or cents - not to furnish a fence -
But an ambulance down in the valley.

"For the cliff is all right if you're careful," they said;
"And if folks ever slip and are dropping,
It isn't the slipping that hurts them so much
As the shock down below - when they're stopping."
So for years (we have heard), as these mishaps occurred,
Quick forth would the rescuers sally,
To pick up the victims who fell from the cliff,
With the ambulance down in the valley.

Said one, to his peers, "It's a marvel to me
That you'd give so much greater attention
To repairing results than to curing the cause;
You had much better aim at prevention.
For the mischief, of course, should be stopped at its source,
Come, neighbours and friends, let us rally.
It is far better sense to rely on a fence
Than an ambulance down in the valley."

"He is wrong in his head," the majority said;
"He would end all our earnest endeavour.
He's a man who would shirk his responsible work,
But we will support it forever.
Aren't we picking up all, just as fast as they fall,
And giving them care liberally?
A superfluous fence is of no consequence,
If the ambulance works in the valley.

The story looks queer as we've written it here,
But things oft occur that are stranger;
More humane, we assert, than to succour the hurt
Is the plan of removing the danger,
The best possible course is to safeguard the source;
Attend to things rationally.
Yes, build up the fence and let us dispense
With the ambulance down in the valley.

Over a century after this poem was written, an idea to cope with the demand of ambulances ramping outside UK Accident and Emergency Departments was developed. A target was set that, by 2004, at least 98% of patients attending an A&E Department must be seen, treated, admitted or discharged in under four hours. This is one of the latest examples of exporting a UK model to Australia that is in the process of being dismantled.  In June 2010, UK Health secretary Andrew Lansley revealed plans to abolish the four-hour rule because this goal was being pursued at the expense of the welfare of the patient. In explaining the rationale for the government’s decision, Lansley cited the example of a hospital in Stafford where, over three years, between 400 and 1,200 more people died than would otherwise have been expected.¹⁹  Despite this salutary lesson and the challenges associated with trialling the idea in Western Australia,13 and ignoring concerns from those with expertise,14 the Australian Federal Government is determined to implement the rule nationwide.15 

Managing madness

As indicated in the introduction, the aim of this book is to explore the underlying causes for health systems having reached tipping point and consider options for altering these underlying factors.  It is understandable that when there is a problem with a health system that the opinion of those responsible for management should be sought. This is exactly what PricewaterhouseCoopers did in 2005 when they interviewed 700 health and business leaders in 27 countries about their health systems. ²⁰The report acknowledged that,

the health systems of nations around the world are threatened by a confluence of powerful trends — increasing demand, rising costs, uneven quality, misaligned incentives. If ignored, these trends will overwhelm health systems, creating massive financial burdens for businesses and governments as well as health problems for current and future generations. Without significant change healthcare systems will be unsustainable by about 2020.

PricewaterhouseCoopers identified seven key features that they claim will create systems that will be built to last as follows:

1. Quest for Common Ground: A vision and strategy is needed to balance public versus private interests in building an infrastructure and in providing basic health benefits within the context of societal priorities.
2. A Digital Backbone: Better use of technology and interoperable electronic networks accelerate integration, standardization, and knowledge transfer of administrative and clinical information.
3. Incentive Realignment: Incentive systems ensure and manage access to care while supporting accountability and responsibility for healthcare decisions.
4. Quality and Safety Standardization: Defined and enforced clinical standards establish mechanisms for accountability and enhanced transparency, thereby building consumer trust.
5. Strategic Resource Deployment: Resource allocation appropriately satisfies competing demands on systems to control costs while providing sufficient access to care for the most people.
6. Climate of Innovation: Innovation, technology and process changes are a means to continuously improve treatment, efficiency and outcomes.
7. Adaptable Delivery Roles and Structures: Flexible care settings and expanded clinical roles provide avenues for care that are centered on the needs of the patient.

All these features relate to the provision of services to people who require treatment. This is another example of the Ambulance in the Valley – but a more contemporary, efficient, high quality, high-tech ambulance. Only a third of the surveyed health executives thought educational and awareness campaigns had been effective, so it is not surprising that suggestions to reduce demand did not feature highly. Using the analogy of bath that is overflowing, the health care system is also overflowing with demand but the ‘health experts’ focused on making changes to the bath rather than turning off the tap. In addition, they perceived solutions from a management perspective and conveniently ignored the fact that it is the management industry that contributes to the exponential increase in costs.

Their first suggestion is for a ‘vision and strategy’ and herein lies another problem that I discovered. I asked a new Commissioner of Health what his vision was for the Health Department.

            “To muddle through” was his reply.

Perhaps that is a better response than another Commissioner who intended to a present his vision for the future to all his departmental staff on. It was cancelled and not rescheduled.

            Proverbs 29:18 Where there is no vision, the people perish...

On reflection, it makes sense that the Commissioner did not express his vision. Perhaps the ‘powers that be’ got to him to indicate that it is not appropriate for a servant of the State to lead with a vision. It is up to politicians to lead and for managers to manage. This is the message emanating from David Hunter, Professor of Health Policy and Management at Durham University. In his book Public Health Policy ¹¹ (p177) he refers to Manchester University Dr Loughlin's dismay at health care managers who believe they are 'servants of the state.' He claims that they exist to implement whatever the ruling political party of the day requires, churning “...out documents full of talk about empowerment and honest dialogue while allowing environments breeding fear and dishonesty to continue.”

Hunter argues that rather than be mouthpieces for the dominant political order, managers have a moral duty to think for themselves, to criticise nonsense wherever it is discovered and to be passionate about the impact their decisions can have on health. Hunter recommends that managers should be chosen for their creative inquiring spirit, diplomacy, ability to relate to others and their skills in guiding and supporting the work of others. Hunter has also claims that,

…terms like 'leadership' are used extremely loosely and devoid of real meaning by politicians.  Previous British Prime Minister Tony Blair and his New Labour team regarded themselves as the leaders. They went on to micro-manage public services like the NHS in a way that drove out or sidelined local leadership.  What they wanted were followers, doers, managers to implement their vision.  They certainly didn't want leaders with minds of their own willing to pursue a different vision (even if it led to the same or better outcomes) or taking risks.  If they had truly wanted leaders, they would have had to accept challenge and diversity and they wanted neither. Consequently there was no space in which prospective leaders could lead. … I'd go further and argue that politicians and managers in the UK (or English) NHS have undergone role reversal by which I mean we've politicised managers and managerialised politicians! ¹

Donald Berwick Former President of the Institute for Health Care Improvement says that every system is perfectly designed to achieve exactly the results it gets.

If the health system is designed to protect the government of the day, then it is probably working well - but I doubt if the average taxpayer would be happy to know that their money is being used for this purpose. In addition, it is alarming to think that health service heads are employed to implement the vision of politicians when these politicians “…develop health policy and health service reforms in an evidence vacuum.”²

Clearly reforms are required within the health care system and there is no shortage of debate, books and opinions about what changes are required. There is a relative lack of focus on what is needed to reduce the demand on health care systems by preventing disease and injury and protecting, promoting and enhancing the health of the community. This book is to help fill this void with the next chapter to consider some of the most demanding diseases and increasing Dis-Ease.

References

1. Oxman AD, Sackett DL, Chalmers I, Prescott TE. A surrealistic mega-analysis of redisorganization theories. J R Soc Med. 2005 Dec 1;98(12):563–8.
2. Klein R. N.H.S. REORGANISATION: THE POLITICS OF THE SECOND BEST. The Lancet. 1972 Aug 26;300(7774):418–20.
3. New Scientist 16 Nov 1972.
4. The trail of the false Petronius. | Goliath Business News [Internet]. [cited 2011 Jan 29];Available from: http://goliath.ecnext.com/coms2/gi_0199-4835198/The-trail-of-the-false.html
5. eMJA: Australian healthcare reform: in need of political courage and champions [Internet]. [cited 2011 Jan 29];Available from: http://www.mja.com.au/public/issues/179_06_150903/van10556_fm-2.html
6. Van Eyk, H., Baum, F., Houghton, G. (2001).
7. Timmins N. The Five Giants: A Biography of the Welfare State. Revised ed. HarperCollins; 2001.
8. Klein R. The New Politics of the NHS: From Creation to Reinvention. 5th Revised ed. Radcliffe Publishing Ltd; 2006.
9. Scott A. Health shake-up needed, not just cash. The Australian Financial Review. 2010;:63.
10. Abbasi K. Curb your enthusiasm. J R Soc Med. 2005 Dec 1;98(12):527.
11. Hunter DJ. Public health policy. Wiley-Blackwell; 2003.
12. Ockham’s Razor - 23 March 2008 - Public policy: It’s so obvious [Internet]. [cited 2011 Feb 7];Available from: http://www.abc.net.au/rn/ockhamsrazor/stories/2008/2195706.htm
13. Smith J, Walshe K, Hunter DJ. The ‘redisorganisation’ of the NHS. BMJ. 2001 Dec 1;323(7324):1262 –1263.
14. Walshe K. Reorganisation of the NHS in England. BMJ [Internet]. 341. Available from: http://www.bmj.com/content/341/bmj.c3843.short
15. Delamothe T, Godlee F. Dr Lansley’s Monster. BMJ [Internet]. 2011 Jan 1;342. Available from: http://www.bmj.com/content/342/bmj.d408.short
16. The Lancet. The end of our National Health Service. Lancet. 2011 Jan 29;377(9763):353.
17. Keegan AD. Hospital Bed Occupancy: More Than Queuing For a Bed. The Medical Journal of Australia. 2010 Sep 6;193(5):291–3.
18. Editorial. Postgrad Med J. 1960 Sep;36(419):535–535.
19. Waiting targets for accident and emergency to be scrapped [Internet]. [cited 2011 Jan 24];Available from: zotero://attachment/22/
20. PricewaterhouseCoopers HealthCast 2020: Creating a Sustainable Future 2009.

* Heraclitus, Greek philosopher

 Chapter 4 What is thing called health?

“Perhaps the most perplexing and ambiguous issue in the study of health since its inception centuries or millennia ago, is its definition.” Sander Kelman A/Professor of Medical Economics, Cornell University.

Starting off on the wrong foot

Once upon a time there was a fit and healthy young man who was running to try to catch up with his friend and he tripped on a rock and fell awkwardly. He lay there dazed for moment as a surge of pain came from his right leg. He howled in agony. His friend who was some way ahead stopped when he heard the agonising cry. He ran back to find his mate nursing his leg that was angled slightly above the ankle.

“You've broken it” he exclaimed.

“Oh no!” his friend replied through gritted teeth.

“Don't worry I think I can help ease the pain by stopping you leg from being able to move.”

The friend broke some branches off a nearby tree and grabbed some bulrushes from the edge of a stream and braided them into a crude rope. He used the rope to tie the branches around the leg despite the protestations from his friend due to the extreme pain caused in the process. Once the leg was fixed in position, the pain lessened. The 'patient' expressed his gratitude to his mate and asked when he could take off the crude splint. “When it’s better” he replied.

2.6 million years later the remains of bodies from the Stone Age have been found showing signs of medical treatment: broken limbs that have been set and healed. Imagine the fame that friend who administered treatment would have received at the miracle he had performed because, no doubt in those days, a broken leg was a death sentence. It is no wonder that people who were able to perform what seemed like miracles were deified and were in demand.¹ In 2,600 BC in ancient Egypt, Imhotep followed the first doctor recorded in history as the Pharoh's physician. He was also the 'vizier' or prime minister and so famous after his death that he was venerated as a god. Even today there is concern that doctors are still inappropriately worshipped for the power to make life and death decisions ² and for which they have earned the reputation for being arrogant. ³ As far back as the time of Marcus Tullius Cicero (106 BC – 43 BC), a Roman philosopher, statesman, lawyer and political theorist, said, “In nothing do men more nearly approach the gods than in giving health to men.”

Imagine how the story would be different if the young man who was running ahead of his friend had noticed the rock as a potential hazard and warned, “Look out for the rock!” If that had happened, and his friend had avoided tripping on it, there would be nothing to show for his friend not becoming a 'patient' as his health was maintained and not compromised by injury. There would be no evidence in ancient burial grounds for preventive action. The friend who saved his mate from a broken leg would not have gained notoriety or veneration for his miraculous achievement. There was no profit to be gained from his action. Several millennia later the situation has changed little in that providing care to people who become sick or injured is more rewarding and lucrative than preventing them becoming sick in the first place. So the young man applying the splint on his friend's leg conceived a health industry that has since blossomed. Given its incredibly long and largely successful history, it seems inconceivable that, like Peak Oil, demand is exceeding the ability to continue to supply services at an affordable cost. 

The health industry has grown to one of the largest in the world and includes hospitals, home health care providers, nursing homes, companies and entities that provide medical equipment, medical supplies, pharmaceuticals, biotechnology and related life sciences. It also includes regulation and management of health services delivery, and administration of health insurance.

An industry that is designed to treat the sick and injured would more accurately described as one that is focussing on the opposite of health. “Illth” sounds like a more accurate description of the core business of the industry, but this invented word has already been taken to mean the opposite of wealth. It was a term coined in Victorian times by social critic John Ruskin to define the economic and social activities that led to no social good. If the provision of services to the ill and injured is a social good, then illth is not a suitable word to describe the industry.

Meanwhile most thesauri suggest that the antonym of health is illness, disease and sickness. Interestingly 'death' is not suggested and yet this would have to be the ultimate antithesis of health. In his Medical Care editorial, Dr Eric Schneider says that, “reducing mortality is one of the most cherished goals of all who are involved in health care. Mortality can be reliably measured and it is difficult to misinterpret or to manipulate the result.”⁴ However it has been known for years that using mortality rates to compare the performance of hospitals is problematic. Florence Nightingale engaged William Farr as a "statistician" to assist her in working out what influenced the demise of her patients. He was among the first to realise that “...clinical risk factors, arrive with the patient at the time of treatment.” Perhaps this recognition that mortality rates are affected by many factors other than the quality of clinical care, distracted her from the more immediate and lethal problem of poor sanitation.⁵

In terms of assessing the outcomes of health care services, death rates are still used. If it wasn't for the stigma associated with the term 'death', “death prevention services” would be more appropriate than “Health Services”. This is supported, not only by Schneider's perspective above but is also demonstrated by the expenditure on attempts at death prevention. In the US it has been estimated that 27.9% of the annual health spending flows to the 5.9% of Medicare enrolees who die within a year.⁶

In the absence of an appropriate term to replace “health”, the accompanying word “care” denotes that a service is provided in relation to a health state that has been compromised. So this is why I have consistently referred to “health care” and not “health” as they are certainly not synonymous. Ironically, however, if the “health” business lived up to its name we would not be faced with Peak Health. If there was an industry that was successful in a reaching the goal of making everyone healthy - there would be no demand for services. This might seem fanciful but “Health for All” by 2000 was declared as a goal in 1981 by Halfdan Mahler, Director General of the World Health Organisation (WHO). He defined "health" as a personal state of wellbeing that enables a person to lead a socially and economically productive life. He also emphasised that it is not just the availability of health services.*

Health for all – or for some more than others?

If all countries, especially developed countries, who agreed to the concept of 'Health for All', had put their money where their mouth was over three decades ago we might not be in the pickle we are now in. We are unable to provide “health care” for all, let alone health for all. In most developed countries about 97% is allocated to the provision of health care services as opposed to where Halfdan Mahler said the emphasis should be  - “to enable a person to lead a socially and economically productive life.” An exception is Japan that instituted a health creation policy in 1978. It led to a law ensuring that at least 5% of their compulsory health insurance expenditure is allocated to preventive activities.⁷ Is it a coincidence that the Japanese have the longest life expectancy? ⁸

If ‘health for all’ has not been achieved, there is a need to explore the reason as it might help explain the  lack of clarity as to what health systems are designed for as discussed in Chapter 3. The first step is to define and understand what health is.

The word is derived from an Old English word hāl or haelth, which is of Germanic origin meaning hale, hearty, whole or sound in mind and limb.  Sissela Bok, Senior Visiting Fellow Harvard University, a writer and philosopher, summarised the history of how health was perceived from the time of the mythical Golden Age of primordial peace, harmony, stability, and prosperity. Professor John Frank in his Founders Network paper describes how the broad philosophical concept of health has swung in emphasis over the centuries between the important role of social and economic factors in determining health status (the ecology of health), and determining the cause of disease and developing specific therapeutic measures for treating illness. In ancient Greece there were two theories concerning health, one associated with the goddess Hygeia, and the other with the god Aesculapius. Hygeia was the guardian of health whereas Aesculapius was concerned with identifying the cause of disease and the treatment of the sick.⁹ The distinction and divide between health and medicine is therefore embedded in a long history.

The Greek poet, Hesiod in the 8th Century BCE, spoke of time when men had lived on Earth ‘‘without evils, hard toil, and grievous disease’’ until Pandora’s curiosity and greed got the better of her. She raised the lid of a box out of which flew ‘‘thousands of miseries [that now] roam among men”. Medical historian Owsei Temkin (1973) refers to the story of Pandora as reflecting views that were common among archaic cultures and are still to be found today. For example, according to actor and Aboriginal activist Kunuth-Monks, Australian Aboriginal people believed sickness and death were caused by someone manipulating the spirit world - arangutia (evil spirits) - to do them harm. This led to “payback” with innocent people being blamed and punished with injury or death by spearing, beating or having the bone pointed at them.

In the late seventies an Aboriginal man was carried into the Emergency Department of a District Hospital in the Kimberly in the remote North of Western Australia. He was obviously seriously ill and needed to be admitted to hospital but I, nor anyone else, could find any cause for his subsequent death other than what we were told by his family. The bone had been pointed at him. Was this an extreme example for the nocebo effect; nocebo being the opposite of placebo? ^9,10  

 Hippocrates said "a wise man ought to realize that health is his most valuable possession and learn to treat his illnesses by his own judgement". 6  Whilst health existed as a concept long before Hippocrates, it was not until between 540–250 BC, that Hippocratic texts in Greece referred to, not only particular diseases and symptoms, but also provided advice regarding health promoting ways of living. In the fourth century AD, Aristotle referred to health as one of the factors contributing to a state of well-being, flourishing, or happiness (eudemonia). At about the same time in India, Ayurvedic writings indicated that ‘‘[h]ealth is the supreme foundation of virtue, wealth, enjoyment, and salvation. Diseases are the destroyers of health, of the good of life, and even of life itself.’’

Over the centuries there was a growing appreciation of what determines health.¹¹ For example in Germany in 1790, Johann Peter Frank in Germany argued "that health and well-being could only be obtained where there was freedom from want and social deprivation." In 1826 Frenchman Louis René Villermé reported on the link between poverty and disease and he also noted that poor living and working conditions led to premature death.  A few years later Dr Rudoldf Virchow concluded from his investigation of an epidemic in the German district of Silesia that,

...the causes of the epidemic were as much social and economic as they were physical. The remedy he recommended was prosperity, education, and liberty, which can develop only on the basis of 'complete and unrestricted democracy.

Virchow's most famous quote is in the first sentence of the following,

Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution”.¹¹

Is this when the limits of medicine were first recognised and the fact that others have responsibility for influencing health? Interfering with this notion was the “miasma” theory for disease causation. The long held belief was that diseases were the result of living in areas that were subject to foul smelling vapours. This conviction was an impediment to Dr John Snow convincing Londoners in 1854 that cholera was conveyed in water. He had to resort to a political act that if used today would probably result in arrest. He removed the handle of a water pump to prevent more people drinking from what he had worked out must be the source of the disease as the cholera sufferers all had one thing in common. They had all used the same water pump in Broad Street, Soho. It would have looked good on a graph to show a dramatic fall in cholera cases following the pump handle removal but in fact the number of cases was already declining. As you can see in this graph constructed by the Rev. Henry Whitehead in 1867, removing access to the source of the infection appeared to make no difference although the graphologist surmised that a recurrence of the epidemic may have been prevented.¹² Permission for picture https://s100.copyright.com/AppDispatchServlet

Cholera outbreak in Golden Square, Broad Street, London 1854. The pump handle was removed when the epidemic was waning and appears to have had no effect, although the Reverend Henry Whitehead, who produced these figures, thought that the closure of the pump may have prevented recurrence of the epidemic

Despite Dr Snow's contribution to the eventual discovery that the bacterium vibrio cholera was the causative organism, it was many years before his evidence was accepted. However, as a result of more organisms being discovered, such as the tuberculosis bacillus in 1882 by Robert Koch, the social and economic causes of disease espoused by Virchow and others lost prominence. Nevertheless the famous physician, Sir William Osler, heralded as the founder of modern medicine, believed that it was not just the Koch's bacillus that predicted the clinical course of tuberculosis but that, “...it was more important to know what went on in a man’s head than in his chest.”

In 1909 in Vienna Ludwig Teleky still realised the need to,

...investigate the relations between health status of a population group and its living conditions which are determined by its social position, as well as the relations between noxious factors that act in a particular form or with special intensity in a social group and the health conditions of this social group or class.

But it was in 1913 that a Minnesota public health* doctor named Hibbert Winslow Hill that put the kibosh on blaming socio-economic circumstances on the causation of disease. He declared as a fallacy that,

...infectious diseases come from 'general bad surroundings.' The truth is that they come solely from certain germs growing in the body, and practically the only sort of ‘bad surroundings' which causes infection is association with one of these infected bodies or with its discharges.

He published a book entitled The New Public Health that influenced this fundamental shift in thinking. He said, “... the old public health was concerned with the environment; the new is concerned with the individual. The old sought the sources of infectious disease in the surroundings of man; the new finds them in man himself.” ¹³

Ironically, when mentioning 'the New Public Health' to public health practitioners today they will assume this is a reference to the launch of the Ottawa Charter in 1986 with the call to refocus on a socio-ecological view of health – the very opposite to Hibbert Hill's perspective that still predominates today despite several attempts since then to restore the balance to consider other influences on health. For example, it was not that long ago that, after my talk on the social determinants of health to a group of public health practitioners, I was followed by a public health physician colleague who was presenting on an infectious disease and he opened his talk with the cryptic comment: “And now from the esoteric to the pragmatic.”

 Attempts to reverse Hibbert Hill's doctrine stem back to earlier times but with limited success. For example the first Professor of Social Medicine at Oxford University, John Ryle said in 1943,

Public health . . . has been largely preoccupied with the communicable diseases, their causes, distribution, and prevention. Social medicine is concerned with all diseases of prevalence, including rheumatic heart disease, peptic ulcer, the chronic rheumatic diseases, cardiovascular disease, cancer, the psychoneuroses, and accidental injuries which also have their epidemiologies and their correlations with social and occupational conditions and must eventually be considered to be in greater or less degree preventable.

Perhaps one of the reasons that “social medicine” did not have the influence that it should was that it evolved during the second World War when the opponents of publicly funded health care in the United States described it as socialised medicine and that it was associated with socialism, and by extension, communism. Thanks to McCarthyism being rampant at the time this couldn’t have been a worse time to promote a movement with a hint of activity that supported the concept that we are all equal and should have equal access to health care. 

In fact socialised medicine was originally conceived at the turn of last century in the United States possibly as a precursor to prevention medicine. A few years later the chairman of the Preventive Medicine Section of the American Medical Association, praised socialised medicine in The New York Times in 1917 saying that it was a way to "discover disease in its incipiency," and to help end "venereal diseases, alcoholism, tuberculosis," and "make a fundamental contribution to social welfare."

The term 'Social Medicine' was used in a few European medical schools prior to the second World War.  For example, Dr Andrija Štampar was appointed Professor of Social Medicine in Zagreb University in 1931. It was he who developed the notion of social responsibility for health and the duty of individuals for the care of their health. He became President of the First World Health Assembly of the World Health Organisation (WHO).7 He played a crucial role in drafting the definition of health that was to be incorporated into the first paragraph of the preamble to the WHO Constitution and subsequently into the International Covenant on Economic, Social and Cultural Rights. The definition, strongly rooted in Western culture, is still used today and is as follows:

Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.

The Constitution further recognised "the enjoyment of the highest attainable standard of health ... as one of the fundamental rights of every human being". This "right to health", as it became expressed in an abbreviated version in many subsequent documents, includes the right to adequate food, water, clothing, housing, health care, education, security in the event of unemployment, sickness, disability, old age or lack of livelihood in circumstances beyond an individual's control.

The crafting of the definition and the focus on the right to health may have been influenced by the harrowing experience that Dr Andrija Štampar had when arrested by the Ustaša police on the third day of the occupation of Zagreb. Following his release he was arrested again by the German police and sent to Graz, where he was imprisoned and interned until the arrival of the Soviet Red Army.

There has been much debate and criticism about the definition of health since it was first conceived in 1948, nevertheless it has endured with no amendments. There have been several suggestions for change since then as the understanding of what determines health emerged from research.^14,15,16,¹⁷.

Is health too important to be left to doctors?

If anyone should have an understanding of what health is you would think it would be doctors.  But dominating the thinking of most doctors was, and from my experience still seems to be, that patients are categorised into just two classes: those who are sick and those who are not. Making a diagnosis from a complaint follows this same bimodal approach. For example abdominal pain can be caused by a range of conditions that would need to be checked with a simple question around each potential cause; is it appendicitis, is it gallstones, is it a peptic ulcer, is it a bowel obstruction, etc? It is simply a case of simply answering “yes” or “no” to each possibility until the underlying cause is discovered from exploring details of the problem, examining the patient, conducting investigations and possibly observing progress over time – watchful waiting. This approach has been described as the 'medical model'. It is a term that was used by psychiatrist Ronald D. Laing in his The Politics of the Family and Other Essays (1971), for the "set of procedures in which all doctors are trained."  It wasn't until just after the WHO definition of health was declared when this narrow dichotomous approach to medicine was first questioned.  The challenge is explained in the late Dr Geoffrey Rose's small but vitally important book, The Strategy of Preventive Medicine.¹⁸

Rose's professor of medicine, Dr George Pickering, for whom he was working, was a world renowned expert in high blood pressure in the sixties. At the time the belief was that you either had hypertension or you didn't. Pickering demonstrated that blood pressure ranges from 'low' and gradually increasing to 'high' so that a graph of average blood pressure across a population looks like the shape of a bell – the famous bell shaped curve that can be applied to almost any measure of populations such as height, weight, intelligence etc where there will always be some that are very tall/large/geniuses etc or short/small/not so smart etc and the average will be at the peak of the curve.  Despite this clear evidence Pickering said,

...it is difficult for doctors to understand because it is a departure from the ordinary process of binary thought to which they are brought up. Medicine in its present state can count up to two but not beyond. ¹⁹

This somewhat derogatory statement about the intellectual capacity of medics is one of the fundamental reasons why the provision of health care services is on an unsustainable path. Rose recognised the importance of Pickering's insight into the nature of hypertension as it can be applied to a multitude of other health and social issues that exist in a continuum. An example of this is the approach to youth suicide that I explored in the late 80s.²¹

As chair of the Western Australian branch of the Australian Association for Adolescent Health I lobbied for action on the issue and as a result a Youth Suicide Working Party was convened. It seemed logical that the working party should prioritise its efforts on the young people who are at greatest risk of suicide. Knowing that those who have previously attempted suicide are more likely to attempt again and succeed compared to an average young person, most of the efforts and allocation of the budget were directed at improving health care services to this group. But psychiatrist Dr Stephan Rosenman indicated in an article in the Medical Journal of Australia (MJA) that to focus on a high risk group will squander resources and that such an approach to suicide prevention might need to be abandoned as an immediate health target.²⁰ He explained that there are multiple risk factors to suicide with each adding a little to the risk, but these risks added together can become significant. But there is no way of knowing which factors are the most harmful as they will vary with each individual and are dependent on their mood at the time, whether they are in an environment and/or culture that induces suicidal behaviour. Rosenman provides an example of unpredictable impulsivity -“Half a bottle of whisky may create a high suicide risk within an hour”.  Whilst it might be possible to be more precise about who is at risk, the number who then 'qualify' as being at risk will diminish. This at risk group will then contribute less to the proportion of all suicides. Many more suicides will come from the very much larger group of people that seem to be at lower risk.

To emphasise this point Rosenman asks us to consider a hypothetical population of 100,000. It might be possible to identify 500 people with a high suicide risk of 10%. This happens to be the 10-year suicide risk in schizophrenia. In other words, over a 10 year period, 50 people with schizophrenia will commit suicide.  The remaining 99,500 people are therefore at the same risk of suicide as the general population - which is about 0.1%. In other words, over a ten year period, about 100 people from a population of 99,500 will commit suicide. So by focusing attention on people considered to be at high-risk will not prevent most suicides. Rosenman also quoted Rose's point that mortality falls more if we reduce the whole population's exposure to factors related to suicide than if we identify and treat high-risk people. It was a revelation to learn that a psychiatrist, who was presumably trained in the medical model focussed on the individual with a mental health problem, appreciated the value of the population approach. It spurred me to write an article on the reasons why public health has been slow to respond to the growing burden of mental illness. ²¹

       To help illustrate this vitally important point and to indicate the alternate approach that needs to be taken, Rosenman used the following diagram to demonstrate the difference between the high risk approach as opposed to shifting the whole population away from the suicide threshold.

This is an example of building a fence at the top of the cliff to keep everyone away from the edge. A more pragmatic analogy is the use of seat belts - a successful population-based approach that has dramatically reduced road trauma injuries since legislation was introduced in the sixties.  It is an inconvenience imposed on all drivers and passengers for the benefit of a minority who will have some protection when they are involved in a car crash. It is summarised in Rose's Prevention Paradox:

A preventive measure that brings large benefits to the community offers little to each participating individual. 

It prompts another question in response to, “what is this thing called health?”  It depends if you are referring to individual health or the health of a population.

Meanwhile, using the example of a suicidal patient, the health of the population is not foremost on the mind of a health practitioner faced with deciding whether the patient needs to be admitted to hospital or not. This approach, with answers determined by binary-thinking clinicians, ultimately leads to about 97% of health care expenditure being focussed on the patients who doctors decide need hospitalisation.  Such patients are the tip of the iceberg and, as Rose said,

The visible tip of the iceberg of disease can be neither understood nor properly controlled if it is thought to constitute the entire problem. 

It seems that this wise aphorism of two decades ago has been lost on those that have preferred to focus their efforts on the “patient journey” and trying to improve their “flow” within the health care system. Whilst developments such as Lean Health Care are important in improving efficiency,²² to invest more in improving the process than on the invisible and growing part of the iceberg makes no sense. “It is far better sense to rely on a fence than an ambulance down in the valley.”

So what should the fence look like?

There were attempts to draw attention to the fact that it is a mistaken belief that “the art or science of medicine has been the fount from which all improvements in health have flowed.” In a report commissioned by the Canadian Government in 1974, Lalonde, claimed that most efforts and vast sums were being spent on treating diseases and yet the main causes of sickness and death are rooted in what he described as a health field concept with four components: human biology, environment and lifestyle elements and with only a limited contribution from health care services. He asserted that if there was a greater focus on the first three of these components, costly diseases and death could be prevented. He proposed health education and social marketing as the tools to persuade people to adopt healthier lifestyles. It must have seemed simple; educate everyone with the knowledge about what is healthy and what isn't – i.e. health literacy – and people will make an obvious choice. The Canadian Government, concerned by the escalating costs of health care (even then!), gratefully received and largely adopted the recommendations of the Lalonde report. It contained 23 possible courses of action including educational programs focussing on diet, tobacco, alcohol, drugs and sexual behaviour directed at both individuals and organisations.²³

It was not long before this emphasis on lifestyle led to a “blame the victim” mentality that persists in some quarters today according to which school of thought is followed. In the “Freedom Model”, that aligns more with neoliberalism, the individual is presumed to be capable of free choices and can be held responsible for health conditions that result from choices they have made. Alternatively there is the “Facticity Model” where behaviour is beyond an individual's control but is determined by facts such as genetic make up and the physical and socio-economic environment. In this way socio-economic position determines behaviour and resulting health status. Followers of the Facticity model will believe that blaming people's poor health on their behaviour is to blame people already victimised by their circumstances. Clearly these divergent views are obstacles to progress in disease prevention and health promotion; terms which are also subject to debate. For example, not long after the release of the Lalonde Report, the US Public Health Service produced a report entitled, “Healthy People: The Surgeon-General's Report on Health Promotion and Disease Prevention”. It gave equal status to prevention and promotion and defined prevention as being related to protection from environmental threats to health and promotion was described as being associated with lifestyle changes. Unfortunately by promoting these two concepts and debating the relative value of each confused the picture and did not help the 'prevention is better than cure' cause.

Meanwhile, weighing into the debate in the UK was Thomas McKeown and his influential book entitled “The Role of Medicine: Dream, Mirage or Nemesis?” ²⁴ McKeown was a professor of social medicine at the University of Birmingham in England during the establishment of Britain’s National Health Service (NHS). He was influenced by his observation that the service’s original promise of universal health care coverage to improve population health and eventually reduce demand on services was not fulfilled. Whilst it was a great achievement to bring all hospitals, doctors, nurses, pharmacists, opticians and dentists under one umbrella organisation that was free for all at the point of delivery, the greater access to medical services resulted in increased demand. This critical observation led McKeown to gather the evidence to claim that it was the “invisible hand” of the rising standard of living that contributed to the modern decline in mortality rather than the provision of health care services. He noted that there was a substantial

improvement in mortality trends in England and Wales between 1875 and the early 30s. Following the introduction of the NHS the trend slowed as shown in the graph

Szreter criticised McKeown for ignoring the major contribution of UK Medical Officers of Health, sanitary inspectors, housing officers, health visitors, midwives, school medical officers etc that had been busy since being first employed in the 1870s.²⁵ Their contribution was recognised in a UK House of Commons Health Committee review of public health in 2001 with a Chartered Institute of Environmental Health Officers submission affirming that mass vaccination programs, the engineering works of the 19^th century, creation of social and welfare structures that addressed the needs of the poor were responsible for the improvement in the population's health. The Institute also pointed out that the establishment of the NHS, whilst welcome, deflected attention away from the ongoing work required to protect and promote the health of the public because NHS was a misnomer – as its focus was on ill health. Professor David Hunter reinforces this point in his book 'Public Health Policy' by saying that the very existence of the NHS “...has helped to ensure the marginalisation of the broader health agenda.” ²⁶

By Mckeown overlooking the pre-NHS contribution of public health measures and social welfare programs in improving everyone's health prior to establishing the NHS in 1948, Szreter claims this played into the hands of the emerging New Right in Britain in the mid 70s that questioned the value of the welfare State. The Victorian laissez-faire, free market economic liberalism became the governing ideology of both domestic and international affairs that gave the greatest scope to the “let the market decide” philosophy. This ideology drove the reduction of all forms of public services and is consistent with the predominant Freedom Model that espouses that individuals are responsible for their lifestyles and behaviour. It is a view that persists as I discovered when posing a question to the Australian Government's Minister for Health, Nicola Roxon and to the opposition health spokesperson at the time, Tony Abbot. At a health conference I asked if they agreed to a quote from the aforementioned book of Rose,

Much can be done by individuals themselves to improve their own health prospects, but whether or not they will actually take such action depends substantially on economic and social structures for which governments are responsible.

Nicola, from the Labor government, responded with a lengthy endorsement of his view whereas Tony indicated that it boils down to individual choice. This is an example of the fact that the definition of health is dependent on which party is in power. The left side of politics will acknowledge that health is determined by a range of factors many of which are influenced by policies that are determined by government. The right side of politics believes that the benefits of economic growth will trickle down* to benefit everyone including providing the opportunity to choose a healthy lifestyle.

Whichever side of politics is preferred; this flip-flopping definition of health with each change in government is not healthy as it takes longer than the government electoral cycle for the impact of health impacting policies to demonstrate their value - or harm.

It was the shifting of the national budgets away from the social services, including health, that was given as one of several reasons given by the WHO Director General for the failure of the Alma Ata Declaration.²⁷ In the late seventies, a group of bold visionaries believed that enlightened policies across all sectors could raise the level of health in deprived populations and thus drive overall development. The declaration, that was made at the International Conference on Primary Health Care in Alma Ata, Russia± in 1978, challenged the medical model to also include social and economic factors. It also acknowledged that prospects for improved health resulted from the actions of many sectors, including civil society organizations. Included in the declaration were goals to achieve fairness in access to care and efficiency in service delivery. But with reducing health care budgets and the predominance of urgent issues such as HIV/AIDS, the associated resurgence of tuberculosis, and an increase in malaria the focus moved away from considering the socio-economic determinants of health.

An attempt was made to restore the balance at the first international health conference convened by the Canadian Public Health Association in Ottawa in 1986. As mentioned earlier this is when the Ottawa Charter (OC) was developed that signalled the appearance of the “New Public Health” (again). It affirmed that

The fundamental conditions and resources for health are peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity. Improvements in health requires a secure foundation in these basic requirements... The prerequisites and prospects for health cannot be ensured by the health sector alone. More importantly, health promotion demands coordinated action by all concerned by governments, by health and other social and economic sectors, by non-governmental and voluntary organisations, by local authorities, by industry and by the media.

The OC included 5 strategies as shown in the box that attempted to move the health promotion agenda beyond professional health educators cajoling a passive public to adopt healthy lifestyles to “...the empowerment of communities, their ownership and control of their own endeavours and destinies.”²⁸ Despite this rhetoric the community was not involved in the Charter's development. The conference was, according to a John Raeburn a participant from New Zealand,

…[a] WHO dominated occasion with the agenda of the conference set by WHO...[with a]...focus on industrialised countries ... [and]...a top down political at the expense of the more human and empowering aspects of health promotion. Its relative  remoteness from everyday life and its diffuse nature, means that it has not seized the hearts and minds of ordinary people that it might have.” ²⁹

Nevertheless it was from the Charter that the Healthy Cities movement was born and spread to many parts of the industrialised world including Australia. Supported with funding and a secretariat from the Australian Government three pilot areas were chosen: Illawarra in New South Wales, Canberra (ACT) and Noarlunga (SA). Other areas attempted to emulate the model but when the central funding ceased, as is the wont of the Federal Government in the (usually) vane hope that the States and Territories will take over, the movement stalled. This did not apply to Illawarra where State and private sponsorship continued and is a good example of the influence of strong leadership that has kept the vision alive. See www.healthyillawarra.org.au

As Director of a Public Health Unit in a rural part of WA we tried to implement a healthy community initiative and followed a comprehensive 'how to ' guide.³⁰ Whilst a number of projects were organised, the momentum was interrupted by a communicable disease outbreak and, yet again, the imperative of needing to respond to urgent medical issue predominated.

When moving to another rural area to establish a Public Health Unit, there was a need to respond to community concern regarding the depression emanating from the rural downturn. On hearing from Professor Martin Seligman of the promising results of his Penn Depression Project ³¹ we decided to emulate this program that provides social and cognitive life skills to upper Primary School students. Whilst the results had some positive aspects they were not as dramatic as we had hoped with no intervention effects for depression.³² On reflection the focus of what became known as the Aussie Optimism Program was on only one of the 5 Ottawa Charter strategies: 'develop personal skills'. Without the other components there is the potential to undermine the success of an intervention. For example if a school tolerates bullying this is not a supportive environment for an intervention that is teaching skills to become more resilient. Since establishing the Aussie Optimism Program, a 'Kidsmatter' initiative has been established nationwide to provide a framework – a healthy school policy - for mental health promotion, prevention and early intervention that is specifically oriented to primary schools, rather than presenting schools with a single defined program. (See www.kidsmatter.edu.au ) 

At the fourth international health promotion conference in Jakarta in 1997 it was declared that comprehensive approaches to health development are the most effective. Those that use combinations of the five strategies are more effective than single-track approaches which are how the Aussie Optimism Program could have been described before Kidsmatter provided the supportive environment for its introduction.  Whilst a healthy public policy applied to the school setting will facilitate health promotion programs in schools, this can be undermined if there is a lack of healthy public policy outside of the education system. For example in Morgan and Ziglio's reflection on the Ottawa Charter paper they indicate that many cross government policies are implemented without adequate attention to their impact on health inequalities.³³

To understand health inequalities it is necessary to work out what determines health and, in so doing, we will also get better understanding of what constitutes health for all. This is the aim of the next chapter.

Refs outake

*

• Health For All means that health should be regarded as an objective of economic development and not merely as one of the means of attaining it.
• Health For All demands, ultimately, literacy for all. Until this becomes reality it demands at least the beginning of an understanding of what health means for every individual.
• Health For All depends on continued progress in medical care and public health. The health services must be accessible to all through primary health care, in which basic medical help is available in every village, backed up by referral services to more specialised care. Immunisation must similarly achieve universal coverage.
• Health For All is thus a holistic concept calling for efforts in agriculture, industry, education, housing, and communications, just as much as in medicine and public health. Medical care alone cannot bring health to hungry people living in hovels. Health for such people requires a whole new way of life and fresh opportunities to provide themselves with a higher standard of living.
• The adoption of "Health for All" by a government implies a commitment to promote the advancement of all citizens on a broad front of development, and a resolution to encourage the individual citizen to achieve a higher quality of life.
• The basis of the "Health for All" strategy is primary health care.

*    Dr C.E.A Winslow defined “public health” as "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals." It is the definition still used today.

*          The well known economist John Kenneth Galbraith provided an interesting perspective on the trickle down effect: “if one feeds the horse enough oats some will pass through to the road for the sparrows.”

±    Renamed Almaty, Kazakhstan in 1993.

4

 How is health determined?

One of the key developments that helped us understand what are the ingredients that lead to a healthy population was the Ottawa Charter (OC) although it has not been without its critics. For example in Morgan and Ziglio's reflection on the Ottawa Charter paper they indicate that many cross government policies are implemented without adequate attention to their impact on health inequalities.³³ Also in their review of OC 's development Ridde, Guichard and Houéto point out that no mention of health inequalities was made in the preliminary versions.

They define the term 'social inequalities of health' as the systematic, avoidable and unjust differences in health between individuals and population sub-groups.³⁵ They acknowledge that the reduction of inequalities was an integral objective of health promotion and the Charter was the only document that had the status of making an international statement on the matter.  What is missing is describing what action needs to be taken. Evans et al in their reflection agree that it does not provide 'marching orders on how to do what is being proposed' but they suggest that it is a 'political document'.³⁶ Morgan and Ziglio provide four reasons for the difficulty in tackling the erosive effect of inequities³⁷* on healthy public policy that I am paraphrasing here:

1. There are many underlying determinants of inequities so the various sectors that influence health need to collaborate in the long term with continued funding to achieve goals that are sustainable – currently this is not happening.
2. There is a lack of evidence for what works in reducing health inequities.
3. When policies to address inequities exist, action plans, that should include performance management and cross sector integration strategies, tend to be missing.
4. Health policies should support individuals and communities to be creative and to sustain their health, but the tendency is for them to focus on deficits, problems and needs with solutions requiring professional resources and dependence on hospital and welfare services.

Other obstacles to progress with the Ottawa Charter have been identified by a group from Spain who point out lessons we can learn from past mistakes. Bacigalupe et al point out that health care services are accountable for achieving activity targets and, when this is applied to health promotion activities that have to deliver discrete “packages”. This is not consistent with the holistic view of health and hinders collaboration with other sectors.  They also refer to the impact of neo-liberal philosophy on decreasing public interventions in social and health issues which is reinforced by the determinants of health being, not only beyond the remit of health services but also, increasingly out of the reach of the influence of individuals, communities and even states due to globalisation. They attribute in part the spread of 'short termism' in policy making to the growing community disaffection with and distrust of political processes, politicians and some institutions. Bacigalupe et al are in accord with Morgan and Ziglio's view that the focus on short term investments – 'policy myopia' - is the enemy of healthy public policies.³⁸

       Whist implementing healthy public policy is challenging, just a year after the Ottawa Charter was declared, Dr Manuel Carballo an epidemiologist working at the WHO at the time indicated there was a long way to go in reorientating health services when he said prophetically,

the health systems of most developed regions have become highly bureaucratised, over structured, regimented and unable to respond to their population’s needs; they are basically medical, curative care systems, creating dependency, unable to stimulate social autonomy or empowerment and are, in nearly all cases, becoming financially deficient ... health plans are developed in an ivory tower by elites who often do not understand the people they are working with, and in many cases do not even know them ... we must try to move towards [a health system] in which we all participate in defining needs and expectations, imposing guidance on the health care system at a political level.

It seems from the review by Wise and Nutbeam,³⁹ that the advice of Dr Carballo was ignored and the OC strategy to reorientate health services has been limited to a few hospitals, community health services and individuals. In their assessment of what progress has been made, they could find no evidence of a change in the proportion of health budgets invested in public health or health promotion since 1986. In Australia they found that since 1999-2000 the public health share of recurrent health expenditure has remained virtually constant at 1.7%. They also noted the similarity between the recommendations emanating from the Ottawa health promotion conference and those made by economist Sir David Wanless⁴⁰ 20 years later in his review of health in the UK suggesting that little has changed in that time. Wise and Nutbeam assert that,

…our inability to reframe the role of health systems to include the promotion, protection and maintenance of the health of populations [their emphasis] and to achieve a redistribution in countries investment in their health sectors points to the need for significant rethinking of the approaches we have adopted to date. [my emphasis].

This is one of the aims of this book to stimulate thinking - and rethinking – to inform: action.

Meanwhile the Ottawa Charter has provided “a reference framework, a philosophy; a set of ideas, of orientations, of directions, of guidelines; a vision; a manifesto; and even… a Bible!” to quote several respondents to a survey of participants at a Public Health Conference in Montreal in 2006 where they were asked if the Charter was useful for today's public health practice. Some perceived the Charter as more of a conceptual or theoretical instrument but in the comments to the review by O'Neill et al, they conclude by saying that Charter is still useful but not easy to apply.⁴¹ I am biased towards this opinion because it has helped us understand what health is and how it is influenced. Also it has had a practical application as described from my own experience with developing the Aussie Optimism Program. So for Huber et al¹⁸ to indicate in relation to the OC that “...WHO has taken up none of these proposals” seems somewhat extreme. But I am in accord with Kickbusch¹⁹ in believing that its future has not yet really come. I would go further:  our future health is dependent on implementing all 5 of the Ottawa strategies underpinned by “...the empowerment of communities, their ownership and control of their own endeavours and destinies.” This last reiterated point is critical as it may help explain “the catastrophic failures of public health” that was announced in an editorial in the prestigious medical journal the Lancet eighteen years after the Ottawa Charter.⁴²  

The need to work with communities as empowered partner was a lesson that a Professor Leonard Syme was learning early in his career.⁴³ He is Professor Emeritus of Epidemiology, University of California, Berkeley and he was involved in several well funded programs designed to promote health. One well known example is Mr Fit: the Multiple Risk Factor Intervention Trial that commenced in 1971 and lasted 10 years. In this $200 million study, Syme and his team screened about half a million men in 22 cities and selected around12,000 participants for a 6-year trial on the basis of being in the top 10% at risk for developing heart disease as indicated by their serum cholesterol, cigarette smoking, and high blood pressure. They were also selected according to how motivated they were and how well they were informed on health matters i.e. their health literacy. Half of the group – the control group - were sent to their general practitioners with their assessment results and the other half – the intervention group – were asked to change their diet, take high-blood-pressure medication, stop smoking, and report frequently to a special clinic. In addition they worked with the participants in cooking low-fat meals and encouraged them to read food labels at supermarkets.

After 6 years of this intensive program there was bad news and good news. The bad news was that there was no statistically significant difference in heart disease rates between the control and intervention groups. The good news is that the control group that were excluded from gaining benefits from the intervention were forced to look for their own solutions. They made use of their personalised information about their health risks and improved their own health by as much as the intervention group – but at much less cost.

It would be tempting to conclude from this that all is required to encourage people to adopt a healthy lifestyle is to provide them with their health risk profile and they will act on the information. If only it was that simple – and judging by the many practitioners that continue this practice two decades later there is a belief that this is true. For example, a review in 2010 by Achterberg et al analysed studies of interventions by health practitioners in their attempt to encourage behaviour change in their ‘patients’; patients being people diagnosed with physical and mental health problems and/or people recruited into the study through contacts with health practitioners. They selected interventions that were focussed on smoking, poor diet and lack of exercise. As a result of their analysis of 23 studies, with many focussed on smoking intervention, Achterberg indicated that the implications for health practitioners was that they should not think, “…that providing knowledge, materials and professional support will be sufficient for patients to accomplish change…”

According to their reviews Achterberg et al suggested that more success is likely with a focus on patient’s risks of damaging their health by continuing their current lifestyle, to encourage them to monitor their behaviour, to set goals and seeking support from social networks.⁴⁴ General practitioners, who are in the front line in relation to seeing about 80% of the population 2 or 3 times per year, are well positioned, but time poor, in being able to act on this suggestion. In countries that provide fee for service payment for which health promotional activity is not billable, this is not a financially viable option. This is the situation in Australia where it has been recommended that;

...clinicians should initiate any elements of best practice that patients will accept. However, once clinicians become aware of the limits to patients' willingness to undertake lifestyle change, they should put aside the lifestyle interventions that patients refuse and consider strategies for harm reduction.⁴⁵

Even if providing people with health information was a sufficient motivator of change and even if harm reduction was successful whilst patients are struggling to do the right thing there are many others, who will queue up behind them, starting to take their first puff, to overeat fatty food and engage in other unhealthy behaviours as there is no activity to identify and intervene on those forces in the community that cause these problems in the first place. So Syme had come to a similar conclusion to his colleague, Rose, across the Atlantic: that health cannot be achieved by focusing exclusively on individual diseases and risk factors. This was the message repeated again by Beaglehole and Bonita in their book ‘Public Health at the Crossroads’.

The New Zealand couple suggested in 1997 that public health practitioners had reached a turning point in history where they had to choose which of two paths to take in future. There is a broad path that recognises the foundations of health that takes into account societal and cultural influences, is motivated by wishing to address inequalities in health and is concerned about poverty and global environmental issues. The alternative is a narrow path that considers health is the absence of disease as a result of adopting a healthy lifestyle, motivated by avoiding the risk of disease especially in high risk groups with an emphasis on technique and clinical and molecular biology. There are advantages to this narrow path in that short term goals can be achieved - a choice that is consistent with electoral cycles. The broader path has potential-long term global benefit but with the risk of failure due to the breadth of concerns. Despite this risk, Beaglehole and Bonita encouraged public health practitioners to choose the broad path and as a result had the potential to enter a ‘golden age of public health’. It was a sentiment that was echoed that same year at the Thirtieth World Health Assembly in 1997 where it was proclaimed that equity and social justice should be the main social targets of governments.  Beaglehole and Bonita also warned that if these broad goals are ignored and public health practitioners continue down the traditional narrow biomedical-focussed “…individualistic path of least resistance, [they] will become marginalised as, at best, a poor relation of clinical medicine.” Guess which path they chose?

A clue to the answer came a year later when the editor of the Lancet, Richard Horton, was forced to urge public health to rediscover its passion. In his commentary he challenged practitioners by concluding; “... if the new new public health is to have any impact today, it needs to reignite its social flame”⁴⁶ 6 years later public health still seemed to be languishing in the dark with the Lancet again having to ask,

where are the zealous physicians and public-health advocates of the 19th and early 20th centuries? Where is the new Jenner, Semmelweiss, Virchow, and Snow? Public health has become complacent. It is failing…Our public-health leaders must replace prevarication with imagination.⁴⁸

That was in 1998. Thirteen years after this challenge the Lancet editor was compelled to write;

There was a time when public health in England was driven by passionately articulated values and compelling research, a time when its leaders were concerned about social reform and political change. England has so many comparative advantages in public health—superb science, a committed body of public health practitioners, proven solutions to some of the gravest health threats facing our populations, and a new generation of students who have an inspiring global vision for public health. Yet today’s leaders in public health prefer to collude with a mendacious government and preside over the decimation of public health in the NHS. Public health is the science of social justice, overcoming the forces that undermine the future security of families, communities, and peoples. Public health leadership in England is failing. It is time for those leaders to discover courage and purpose. ⁴⁷

I will leave it for you to decide whether there will be an adequate response to this challenge. Meanwhile an imaginative approach was formulated in the US around the time that Beaglehole and Bonita were encouraging public health practitioners to step up.

Syndemics  

Medical anthropologist Merrill Singer⁴⁸ studied the mutually reinforcing nature of health-related problems such as substance abuse, violence, and AIDS, that disproportionately impact inner city neighbourhoods burdened by economic hardship, deteriorated infrastructure, social disruption, malnutrition, and inadequate health care. He noted the traditional compartmentalised approach that health agencies used was engrained in their financial structures, scientific frameworks, and statistical models of health. They responded as if each affliction can be prevented individually by understanding its unique causes and developing narrowly targeted interventions. This is despite the Jakarta Declaration recommending that utilising combinations of the five Ottawa Charter strategies are more effective than single-track approaches. In view of absence of a descriptor of the reinforcing relationship between various health issues, and the neighbourhood environment he conceived the term ‘syndemic.’ It is derived from the Greek prefix syn, meaning together, thereby implying that more than one epidemic is mutually reinforcing or interacting synergistically. It infers the need to pay closer attention to the connections that have always existed but are often overlooked, unquestioned, or neglected in the conventional approach to the study of the occurrence and distribution of disease i.e. epidemiology.

Whilst he did not use the term, Rose was well aware of the concept of syndemics when he described, for example, the relationship between mean alcohol intake and the prevalence of alcoholism, gambling, depression, suicide rates, aggression and violent crime. Rose also acknowledged that Hippocrates had recognised the association between diseases and societal issues when the 5^th Century BC physician advised people who were moving to a new city to first find out if the inhabitants were ‘…fond of excessive drinking and eating and prone to indolence, or else fond of exercise and hard work.’

 Applying health to whole populations was a concept that, according to Rose, did not resurface until 1897 when the French sociologist Emile Durkheim described ‘social reality’ as determining individual behaviour. This is in contradistinction to believing that individuals collectively contribute to the characteristics of a population. Whilst Rose perceived this view as extreme he did believe that, ‘…society is important in public health because it profoundly influences the lives and thus the health of individuals”.’¹⁹ His opinion is somewhat different from that espoused 5 years earlier by his Prime Minister who berated those who, “…are casting their problems on society. And who is society? There is no such thing!” ⁵¹

Perhaps this neo-liberal philosophy is one of the reasons why there has been comparatively little research into changing the characteristics of society although Rose blamed medicine because it ‘has been preoccupied with concern for individuals.’ It is still the bias of medical research funding bodies as some of us found from recent experience (in 2011).  We were advised not to bother seeking a grant to investigate a program to improve the health of a community group as ‘they’ are only interested in funding randomised controlled trials* that demonstrate a change in the health status of individuals.  As research into measures that can alter the characteristics of populations is largely unexplored there is a relative lack of evidence to inform the development of policies that influence the health of populations. We are also, therefore, less able to adequately define health and this is one of reasons it is still the subject of debate that is not as informed as it could be.¹⁸ In addition, it is a debate predominated by Western ideas with limited attention to the positive concept of health as espoused by American-Israeli medical sociologist Aaron Antonovsky⁵² 

Your good health!

“Salute!” is Italian for ‘cheers’ - a toast to good health and is derived from the Latin ‘salu’ so Antonovsky added the Greek ‘genesis’ to denote the creation of health or, ‘saltogenesis.’ Like Štampar, it was the threats to health associated with World War II that inspired him to conjure up the concept. He studied the impact of extreme stress on menopause in Jewish women who survived concentration camps and found that some maintained their health and had a good life.  This led him to believe that there are biological, material and psychological factors that make it easier for people to cope. He described these factors as General Resistance Resources (GRRs) that enabled people to consider that they had lives that are consistent, structured and understandable. Examples of GRRs include money, knowledge, experience, self esteem, healthy behaviour, commitment, social support, cultural capital, intelligence, traditions and attitude to life. Unless these resources are used they are of limited value, so Antonovsky developed a second aspect; a ‘collective sense of coherence (SOC)’ that are composed of 3 components:

(i) comprehensibility - the cognitive component;

(ii) manageability - the instrumental or behavioural component; and

(iii) meaningfulness - the motivational component.

Antonovsky theorised that SOC was mainly formed in the first three decades of life and would remain unchanged unless there was a major upset in a person’s or community’s life. This is because most people reaching their fourth decade would have had enough education, life and work experience to be independent and resilient.  A year before his premature death, Antonovsky published an article that summarized the evidence up to 1992⁵³  The Year before the Institute for Future Studies in Stockholm published a background document that focussed on an element that, whilst not highlighted, might be implicit in Antonovsky’s thesis that health is dependent on access to SOC. Equity is the apect that Dahlgren and Whitehead included in their document prepared for the WHO entitled, ‘Policies and Strategies to promote social equity in health.’⁵⁴  They summarised their perspective on the main influences on health by drawing their infamous rainbow or onion with a series of layers denoting as follows; the structural environment; the material and social conditions in which people live and work determined in turn by housing, education, health care, agriculture etc., followed by mutual support from family, friends, neighbours and the local community that may influence the choice of food, drinking and smoking habits taken by individuals. Less modifiable are the central characteristics determined by age, sex and genetic make up.

They divided the layers into four to represent the levels of policy intervention as follows; Policy Level 1 aimed at international and/or national long term structural changes such as economic strategies, trade and environmental agreements between countries. Policy level 2 aims to improve living and working conditions by, for example, social security benefits, access to health care, food and nutrition policies associated with the agriculture sector and employment policies. Policy Level 3 focuses on strengthening support to families and individuals in recognition of the intrinsic strengths within communities.  Policy Level 4 relates to health education and providing support to groups with the unhealthiest lifestyles. In a statement that echoes that of the Ottawa Charter the authors recommended that all 4 levels needed to be employed as they would be mutually reinforcing, or synergetic, as they put it, a concept not dissimilar to the approach to, yet to be invented, syndemics.  Included in the wealth of information about syndemics linked to the website of the US Centre for Disease Control and Prevention is the following crucial point that needs to be factored into the ‘onion’;

We have for decades been able to anticipate and enumerate a number of health challenges that will arise as a our world undergoes profound social and physical change, but we have not had a way to think about precisely what it means for these things to happen at the same time, how they will influence one another, nor how our responses will affect the dynamics of what unfolds in an increasingly complicated and interdependent global ecosystem.

In an attempt to include consideration of the impact of the global ecosystem on health, Barton et al added some onion layers. [to use diagram email: journals.permissions@oxfordjournals.org ]

It was partly inspired by the Dahlgren and Whitehead figure and the eco-system model of human habitats by Duhl and Sanchez.⁵⁵ It includes the ‘built environment’ that make up human settlement such as buildings, spaces, streets and networks. How these are designed and the accessibility of pedestrian and cycling facilities, parks and playing fields influences how easy it is to exercise. The ‘natural environment’ refers to issues such as clean air and water; the local economy relates to access to work and income and the ‘community’ refers to social networks and the degree to which they are supportive.

Barton et al bemoan the fact that despite advocacy for sustainable development, the development industry in carries on regardless of the 27 principles of a declaration in 1992 at the United Nations Conference on Environment and Development in Rio de Janeiro. This is demonstrated in Europe by the

…expanding peripheral city areas with low-density, use-segregated, car-based development that not only uses land profligately but reduces the viability of local services, makes walking impractical because of distance and deters cycling. The fashionable office, retail and leisure parks that spring up in the wake of road investment typically rely on 90–95% car use. The segregation of land uses is undermining the potential for integrated neighbourhoods and local social capital. Unsustainability is literally being built into our cities. In this context, health is a casualty. The decline in regular daily walking and cycling is resulting in increased obesity and risk of diabetes and cardiovascular diseases. Social polarization of opportunity is exacerbated. People tied to locality—elderly people, children, young parents, unemployed people and immobile people—are increasingly vulnerable. The decline in local facilities, the reduction in pedestrian movement and neighbourly street life all reduce opportunities for the supportive social contacts so vital for mental well-being. Health problems are being accumulated for the future, which will make the present problems of health service delivery look trivial by comparison.⁵⁶

I have highlighted this last point in this longer than usual quotation in view of the fact like many of my predecessors and health service managers, the human ecology model of a settlement is rarely considered as a driver of increasing demand on health care systems. So perhaps it’s not surprising that health care services are not included in the Barton et al model of the determinants of health and wellbeing.

Although we are getting closer to answering the question, ‘what is health?’ there is more to consider as events unfold, knowledge increases and new threats to health emerge. Some of these factors have been hard to identify prompting a series of programs on the Australian Broadcasting Corporation’s Radio National entitled ‘the Mystery Factor’. It’s a mystery we need to explore if we are going to get closer to the source of Peak Health, but it was a mystery that was unravelling in the 90s in Western Australia as we shall discover in the next chapter: The Mystery of the Angst

*              Health inequalities are defined by the WHO as the differences in health status or in the distribution of health determinants between different population groups. When health inequalities are imposed by others and are outside the control of the individuals concerned this is unjust and unfair, so that the resulting health inequalities also lead to inequity in health.q.v.

* A randomised controlled trial (RCT) selects suitable study subjects that are randomly allocated using a computerised tossing-a-coin process to decide who receives one or other of the alternative treatments under study. After randomization, the two (or more) groups of subjects are followed up in exactly the same way to determine the differences in outcome.

5

The mystery of the angst

The mystery factor was the title chosen by Johanna Bartels to describe a series of four programs on the ABC's Radio National in November 1998.¹ Professor Len Syme, who we met in the last chapter, led the first program and it was he who probably first alerted me to the great challenge we face with providing sufficient health care to meet demand back in 1996 when he asked,

How is it possible that after 50 years of massive effort, all of the risk factors we know about, combined, account for less than half of the disease that occurs? Is it possible that we have somehow missed one or two crucial risk factors?

Syme suggested that about 60% of preventable morbidity and mortality are located neither within individual sovereignty nor the domains of individual behaviour, lifestyle or 'risk' but within social organisations. He called urgently called for “...a paradigm shift in the conceptual framework and problem solving strategies for public health.” ²

Eight years later, without any paradigm shift having occurred, Syme was compelled to say,

If we think our medical-care system is in trouble now, we ain't seen nothin' yet. Our only hope is to develop better proactive strategies for preventing disease and promoting health, rather than waiting to fix problems after they occur. And 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 organize 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. ³   

5 years later, during the ABC radio program, Syme provided further insight into the direction that needs to be taken in the light of his extensive experience and research. He related his studies of the impact on health of Japanese migrating to Hawaii and to California and found that there was a fivefold increase in heart disease amongst the migrants, but half of the migrants in California had no increase in disease at all. Those who had adopted Western ways had the highest rates of disease, whereas those who retained traditional Japanese ways had rates as low as in Japan, after accounting for risk factors such as diet and smoking. The Japanese who retained their traditional lifestyle observed that many Americans appeared lonely. This prompted Prof Syme to further explore social support as a key factor. Whilst significant, further studies did not suggest this was the most important factor. It was the studies of Whitehall Civil Servants by Professor Michael Marmot (who featured next in the series of programs) that led him to conclude that the key is control of destiny.

The studies demonstrated that the civil servants who had high demands at work and very little latitude in discretion for dealing with those demands, had the very highest rates of disease. Those at the top had the greatest latitude as they had the most power and could access support as they needed it. Those at the bottom of the hierarchy had the least power and this adversely impacted on their health with a step wise gradient between top and bottom.⁴ The implications of the results were recognised by the European office of the World Health Organisation (WHO) in Copenhagen who approached Marmot and his team at the International Centre for Health and Society and asked if he could translate his work into ten messages that could inform discussions potentially leading to high level policy changes. As a result a highly influential document was published entitled The Social Determinants of Health: The Solid Facts.⁵ The ten messages are abbreviated in box 1 and we will need to revisit the policy implications because if these 10 items determine health then by enhancing or mitigating these factors will help alleviate Peak Health.

THE 10 STEPS

From “ The Solid Facts – The Social Determinants of Health” (WHO)

1. THE SOCIAL GRADIENT

People’s social and economic circumstances strongly affect their health throughout life, so health policy must be linked to the social and economic determinants of health.

2. STRESS

Lack of control over work and home can have powerful effects on health.

3. EARLY LIFE

Important foundations of adult health are laid in early childhood. The effects of early development last a life-

time; a good start in life means supporting

mothers and young children.

4. SOCIAL EXCLUSION

Social exclusion creates misery and costs

lives. People living on the streets suffer the highest rates of premature death.

5. WORK

Stress in the workplace increases the risk of disease. Jobs with both high demand and low control carry special risk.

6. UNEMPLOYMENT

Job security increases health, wellbeing and job satisfaction. Unemployed people and their families suffer a much higher risk of premature death.

7. SOCIAL SUPPORT

Friendship, good social relations and strong supportive networks improve health at home, at work and in the community. Belonging to a social network makes people feel cared for.

8. ADDICTION

Individuals turn to alcohol, drugs and tobacco to numb the pain of harsh economic and social conditions and suffer from their use, but use is influenced by the wider social setting.

9. FOOD

Healthy food is a political issue.

10. TRANSPORT

Healthy transport means reducing driving and encouraging more walking and cycling, backed up by better public transport.

To emphasise the importance of social status as a determinant of health it is worth quoting Marmot’s colleague Professor Richard Wilkinson. He commented in a BMJ editorial on a study of the health of people living in poverty in Northern England compared to affluent people.  He indicated that if the risks to health from living in poverty resulted from exposure to toxic materials, “…then offices would be closed down and populations evacuated from contaminated areas.”⁶

The third program in the Mystery Factor series featured Dr Bruce McEwen from Rockefeller University in New York who specialises in the interrelationship between the nervous system and endocrine systems – a neuro-endocrinologist. McEwen developed the concept of allostasis derived from Greek with 'allo' meaning 'variable' and 'stasis' refers to 'stability'; so together they mean 'achieving stability through change'. It is a more sophisticated term than the colloquial term ‘stress’ which has a multitude of interpretations whereas allostasis refers to the fact that in response to a challenge, the body put outs (i.e. secretes) cortisol and adrenalin both of which belong to a class of ‘fight-or-flight’ glucocorticoid hormones called catecholamines. These gear the body to respond to and survive an immediate challenge or threat and to then restore the body to its normal resting balanced state i.e. homeostasis. It is this stability of key physiological characteristics such as body temperature, energy balance, blood composition that maintain life.

The ‘fight-or-flight’ response was critical for survival during the early history of humankind and is designed to maximise the ability to deal with an urgent threatening situation, but when the hormones continue to be secreted in response to longer term challenges; this is when damaging health effects can occur. McEwen’s interviewer, paediatrician turned broadcaster Dr. Norman Swan, provided an example of long term challenges of work-related stress; when you are told what to do, with no control on how and when to do it. McEwen added further examples of family conflict, and living in a state of anxiety in a dangerous neighbourhood necessitating constant vigilance. He also suggested that the higher levels of cortisol in people living in these adverse environments stimulate hunger and the consumption of additional calories associated with raised catecholamines and insulin assists the conversion to fat. McEwen also referred to a study showing that family stress increased the incidence of insulin dependent diabetes. From animal studies it is thought that the stress is enhancing some of the immune mechanisms responsible for destroying the insulin secreting pancreas.

Since 1998, when these programs were broadcast, these concepts have been further explored including the impact of high allostatic load on children and the implications for their future health prospects. Danese and McEwen reported that children exposed to maltreatment were found to have a smaller volume of the part of the brain called the prefrontal cortex.⁷ The prefrontal cortex is believed to be responsible for orchestrating thought and action in accordance with goals. Children with a smaller volume prefrontal cortex than average tend to be inattentive and /or hyperactive and impulsive.  These are signs of Attention Deficit Hyperactivity Disorder ADHD (or ADD if hyperactivity is not a component) that is known to be associated with the function of the prefrontal cortex as well as other parts of the brain.⁸

Danese & McEwin conclude by saying that adverse childhood experiences are associated with changes in the nervous, endocrine, and immune systems that persist into adulthood exerting long-term effects on biological aging and health. This statement has enormous implications for future demands on health care systems that we will explore further in Chapter 6. Before doing so a 4^th program in the Mystery Factor series considered the implications for Australia. It began with Swan interviewing an occupational physician Dr Niki Ellis who was chair of the now defunct Royal Australasian College of Physicians’ Social Policy Committee. She confirmed the health hazards of enduring a high workload with very low level of control and added that another source of stress is conflict between management and workers, “which appears to be endemic in the Australian situation.”

To address the situation, Dr Ellis indicated that it was up to senior managers to, not only focus on work outputs, but also job satisfaction; but she said few managers had these skills. In support of this perspective, Swan quoted from a speech by the manager of Telstra who said the quality of leadership in Australian managers was ‘appalling’- a view that resonates with components of Chapter 2 on Management Madness.

Swan also interviewed Professor Bob Douglas, who was then Director of the National Centre for Epidemiology and Population Health at the Australian National University in Canberra. Douglas reinforced the evidence of Syme and Marmot that socio-economic status is one of the most profound predictors of the likelihood that people will live long and healthy lives. Swan pointed out this has been known for centuries, but Douglas emphasised that it was not known that there are marginal returns from concentrating exclusively on people who were affected by their social circumstances and their resultant risk behaviours such as smoking, poor diet and lack of exercise. (Over a decade later this recognition appears not to have translated into practice in accord with other countries as indicated in Chapter 4).

Douglas also indicated that Marmot’s ten points were being taken seriously. (Again the evidence would suggest that the points were not taken seriously enough: a decade after this radio program the gap between rich and poor widened and activities in the UK to tackle the problem were ineffective.^9,10 Also in Australia in 1994, 7.6% Australians lived in poverty and in 2006 it increased to 11.1%;, there was a 39% increase in people turned away from disability services; homeless and homelessness services increased by 19%; emergency relief services turned away an average of 100 eligible people in 09/10 an increase of about 47%; and there are many more statistics summarised by the Australian Council of Social Services¹¹ to demonstrate that the policies recommended in Marmot’s 10 steps were not implemented.

The series of ABC Radio National programs helped unravel some of the mystery factors that contribute to the determinants of health but a mystery remained as to the underlying cause of angst that McEwen alluded to in his interview.

The symptoms of this angst were noted several decades ago in Western Australia (WA) by a general practitioner, Dr Dick Roberts. He reflected on his experience over the preceding decades of the link between increasing urbanization and affluence and the parallel increase in suicide, homicide, alcoholism, anxiety and severe mental disturbances. It caused him to question about where western society was heading. ¹² This was not unrelated to the findings of a survey conducted by Professor D’Arcy Holman when he compiled a very  comprehensive review of Community Child Health services and published a four volume report with many recommendations to make the service more contemporary and more financially viable.¹³

Holman consulted with over 1000 staff throughout the 2,525,500 square km of WA and near the start of his fact finding tour he visited members of the team at a Child and Family Health Development Centre where I was working as a child health medical officer. He asked us as a group what was our main concern. The response was unanimous,

“Child Abuse!”

Holman looked astonished.

“But that’s an issue for the Department of Child Protection.” he remonstrated.

The staff, who had been looking forward to this review, hoping it would boost what had been a neglected service, were somewhat disappointed and deflated by his response. We were concerned that his review would not capture the anecdotal evidence from staff that some growing underlying societal issues were responsible for “symptoms” such as child abuse.  But, after consulting with many more staff around the State, he indicated in his report that Community Child health nurses,

…felt under siege from the community demand for pastoral care, counseling and social welfare services…to render assistance to persons suffering from psychosocial morbidity.

He defined psychosocial morbidity (PSM) as a state of human distress resulting from personal conflict within an individual, and/or from an adverse social environment. He noted the general perception that the demand for help with coping with PSM had greatly increased since the late 1970s. It was difficult to describe as there was a lack of factual information and, “if you can’t measure it, it doesn’t exist” - and, I would add that, it is handicapped by having a label that is not user-friendly. Imagine if PSM had been a formally recognised condition. The extent of the problem could have been determined, it could have been measured to see if it is increasing, decreasing or staying the same and the data would provide the evidence and impetus to address it.

Prof Holman enumerated some theories to explain the phenomenon of PSM that are important to reiterate here. This is not only because it was an issue that scored highest as the number of times it was raised by Community Health staff with Holman, but also because there were few discourses on this fundamental issue at the time and the consequences of ignoring them are now being realised.

Demand Theories

• Increased materialism at all levels in society have caused people to live beyond their means with resultant stress from financial pressures. Many people considered that unrealistic media images had contributed significantly to this problem.
• Financial pressures from the economic downturn in the rural sector, and other macro-economic factors have induced stress through a forced reduction in living standards.
• Increased expectations of others in satisfying personal needs, a reduced sense of parental responsibility, and greater ease of separation have resulted in stress from family dysfunction and break-up.
• Delayed childbirth in women with established working careers has produced a conflict in role and financial position. An increased number of women have been expected to fulfil a dual role of home maker and financial co-provider, with resultant family stress.
• De-institutionalisation, whereby the sick, the disabled, the frail aged, the mentally ill, the homeless, delinquents, and criminals undergoing rehabilitation have moved from large centralised institutions into the general community has placed increased stress on spouses, relatives and neighbours.

Supply Theories

• A reduction in the interest in religion has displaced demand for assistance previously serviced by the church.
• The financial realities of modern general practice have reduced involvement of private medical practitioners in servicing demand, resulting in displacement to the public sector.
• Increased family mobility and greater participation by ‘grandmothers’ in the workforce has displaced demand previously serviced by the extended family. The situation has been further exacerbated by the higher proportion of parents without partner support, or older children to help out.
• Dormitory suburbs resulting from double income working families, and a general reduction in the level of concern for others (include interest in unpaid charitable work) has displaced demand previously serviced by neighbours, friends and volunteers.
• The willingness of the public sector to service the area has legitimised demand, and has resulted in community expectation that publicly-funded assistance will be provided.

On the other side of the country, at around the same time as Holman’s review, paediatrician Professor of Community Child Health at the University of Newcastle New South Wales Graham Vimpani AM co-edited with developmental paediatrician Dr Trevor Parry. Community Child Health in Australia: An Australian Perspective. They listed the following threats; low socio-economic status, poverty, unemployment, the cumulative nature of disadvantage, dysfunctional families and changes in family structure, race and ethnicity, nutrition and biological influences. They also noted that the decline in social support that previously buffered against the negative impact of these psychosocial environmental influences on families.¹⁴ In the chapter, entitled Attitudes to the Role of Parents, in Vimpani’s book, Connell described the situation as a ‘suburban neurosis’ to describe the impact on mothers left at home in the relative isolation of an urban environment.¹⁵

The negative impact of the changing Australian social landscape was also identified by social analyst Richard Eckersley in the late 80s.¹⁶ Eckersley is frustrated by the lack of progress since then and the fact that the underlying issues still need to be tackled.¹⁷  For example a review by Matthews et al demonstrated that mental disorders are the largest “contributor” to disability in young Australians with anxiety and depressive disorders being the leading single cause.¹⁸ They recommended, like Eckersley many years earlier, the provision of accessible and youth friendly health care as well as ensuring the effectiveness of transitions from child health services to adult health services.

In his 1993 book, Reinventing Australia, another Australian social analyst Hugh Mackay added to the realisation that a myriad of changes occurred in Australian society in the preceding decades which have had a negative impact on families.¹⁹ In relation to children he stated,

Today’s children are thought to be under more pressure at school, more pressure at play and more pressure from a media, marketing and social environment more stimulating and seductive than the environment in which their parents grew up.

Whilst these impacts on children have become more prominent, the supports available to families, that may have mitigated against the negative influences on child health, have declined. Lisbeth Schorr, lecturer in social medicine at Harvard University lists in her book, Within Our Reach, the following reasons for the increasing strain on parents when the availability of informal support is lessening;

• More women, including many more mothers of young children are working, the vast majority in response to economic pressures.
• More children are growing up in poverty and many in concentrated poverty, subject to the strains that low incomes and depleted neighbourhoods impose on family life.
• Greater population mobility not only means fewer relatives and friends nearby to lend an extra pair of hands, but also that parent(s) and children themselves move much more frequently than did earlier generations, adding yet another element of strain.
• Greater mobility also means the erosion of the sense of community which develops over generations of living in proximity (whether or not reinforced by kinship ties) that provided structure and a framework for the process of child rearing.
• For many Americans, community has been replaced by a climate of anonymity, often accompanied by alienation, hostility and violence.
• Child rearing itself has become more difficult. Gone are the clear shared values and precepts to be passed on to the children. From outside of the family have come the lure of drugs and powerful pressures to define oneself by acquiring material goods. The pace of change is so rapid, values are so much in conflict, that everyone, including parents of young children, has to make up instant new rules to live by - a task that older societies never imposed.

Professor of Human Development at Cornell University, James Garbarino explores the social equivalents of environmental pollution in his book, Raising Children in a Socially Toxic Environment.²⁰ He refers to ‘contaminants’ that demoralise families and communities such as disruption of family relationships, despair, depression, paranoia, violence, poverty and other economic pressures on parents and their children. Garbarino claims that these are the elements of social toxicity that affect all children and youth, but with greater toxic effect during the antenatal period and in infancy. He claimed that the “social and cultural poison” was higher in 1998 than it was 40 years earlier.

It is perhaps no coincidence that this was at a time when a measure of social health was at its peak as we will discover on page 12

Meanwhile Garbarino warns that as the social environment becomes more socially toxic, it is children who show the effects first and worst. And the children who can least afford to be compromised by social toxicity are those who are most vulnerable as a result of having accumulated developmental risk factors such as poverty, racism, abuse, neglect, absent or incapacitated parents are the most vulnerable. But Garbarino makes the following analogy to demonstrate that all will be affected by social toxicity if it is allowed to continue:

Imagine living in a city plagued by cholera. In this city, the challenge to parents to keep kids healthy would be overwhelming. Yes, the most competent parents and those with the most resources would have more success delivering drinkable water to their children than would other parents. But even these "successful" parents would sometimes fail. Would we blame them for their failure, or point the finger at the community's failed water purification system? In a socially toxic environment the same principle holds. So let us put aside blaming parents and take a good hard look at what we all can do to lend a hand with the challenging task of raising children in a socially toxic environment. What we do on the policy front in support of parenthood in detoxifying the social environment will go a long way to enhancing the quality of life for children and youth in the decades to come, when we really are facing the transition to the 21st century as issues of resiliency and coping become ever more important.

Garbarino warned in 1995 that “…unless action was taken, the situation would continue to deteriorate.”²⁰

Again do we have to blame the absence of measures of ‘social toxicity’ to account for the fact that Garbarino’s call for action was ignored?

There was an attempt to measure deteriorating toxic neighbourhoods by seeing whether residents of neighbourhoods with a high percentage of boarded-up stores and homes, litter, and graffiti - measured collectively as the Broken Window Index - experience a higher incidence of disease and premature death than do people who live in healthier neighbourhoods.²¹ Dr Deborah Cohen from the RAND corporation and her colleagues found that even after taking away the influence of poverty in their analyses, compared to ‘spruced up’ neighbourhoods;

• Residents of deteriorated neighbourhoods had higher rates of gonorrhoea and were likely to die earlier from cardiovascular disease and homicide.
• A neighbourhood’s collective efficacy — i.e., residents’ willingness to help out for the common good — was associated with lower rates of premature death in general and death from cardiovascular disease and homicide.
• However, the association between collective efficacy and lower rates of premature death was not seen in neighbourhoods with a high percentage of boarded-up stores and homes, litter, abandoned cars and graffiti i.e. a high Broken Window Index.

In another study that also controlled for socioeconomic status, Aneshensel and Sucoff found that adolescents living in ‘dangerous’ neighbourhoods in Los Angeles had higher levels of depression, anxiety, and conduct disorders than those from more orderly neighbourhoods.²²

Fleming et al conclude in their review that opportunities for social interaction and physical activity, as well as cues from the environment, may trigger a variety of emotional responses and either facilitate or reduce health-related behaviours such as exercising, indulging in substance use, and maintaining a healthy diet. ²³

In Australia a study examining the emotional adjustment of Australian children aged between 9 and 11 indicated that when they lived on commercial streets in inner-city Sydney they were more lonely, more likely to dislike of other children and had feelings of rejection, worry, fear, anger, and unhappiness than their counterparts in strictly residential neighbourhoods. This difference was apparent even after the researchers, Homel and Burns, removed the effects of family composition and social class from their results.²⁴

The bottom line is that where you are born and raised influences your health. To convey this point more graphically, the Public Health Agency of Canada tell this story of Jason on their website;²⁵

Why is Jason in the hospital?
Because he has a bad infection in his leg.
But why does he have an infection?
Because he has a cut on his leg and it got infected.
But why does he have a cut on his leg?
Because he was playing in the junk yard next to his apartment building and there was some sharp, jagged steel there that he fell on.
But why was he playing in a junk yard?
Because his neighborhood is kind of run down. A lot of kids play there and there is no one to supervise them.
But why does he live in that neighborhood?
Because his parents can't afford a nicer place to live.
But why can't his parents afford a nicer place to live?
Because his Dad is unemployed and his Mom is sick.
But why is his Dad unemployed?
Because he doesn't have much education and he can't find a job.
But why ...?"

Winston Churchill said in 1943 that “We give shape to our buildings, and they in turn shape us” and this is consistent with a study by King et al that concluded that neighbourhood environments seem to play a pivotal role in the accumulation of biological risk and disparities therein.²⁶

^{Measuring Angst}

There is no recognised measure of psychosocial morbidity nor suburban neurosis nor ‘stress’ so there is no way to assess whether it is increasing or decreasing over time. However there is what might be considered to be a related measure that was developed by the Fordham Institute for Innovation in Social Policy in 1987: the Index of Social Health.  It is based on sixteen social indicators: infant mortality, child abuse, child poverty, teenage suicide, teenage drug abuse, high school dropouts, unemployment, weekly wages, health insurance coverage, poverty among the elderly, out-of-pocket health costs among the elderly, homicides, alcohol-related traffic fatalities, food insecurity, affordable housing, and income inequality.  The late Marc Miringoff, the director of the Fordham Institute, pre-empted the concept of syndemics in his premise that American life is revealed not by any single social issue, but by the combined effect of many issues, acting on each other. In looking at social problems that affect Americans at each stage of life—childhood, youth, adulthood, and the elderly—as well as problems that affect all ages, the Index seeks to provide a comprehensive view of the social health of the nation. 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 with an apparent inverse relationship with the Gross Domestic Product (GDP) producing the alligator jaw effect shown in the graph 1 below

Graph 1

There appears to be a cost attached to the increase in the Gross Domestic Product (GDP), and it is the most vulnerable who suffer the most, as indicated by Miringoff who said,

The decline in the social health of children and youth tells us something about the future shape of our society.

In 2009 (the last year for which complete data are available), the Index of Social Health stood at 51.7 out of a possible 100—down 2.4 points from the previous year and 6.6 points from 2007. This score is the lowest in thirteen years. Overall, between 1970 and 2009, the Index declined from 64.9 to 51.7, a drop of 20 percent.²⁷

This apparent anomalous inverse relationship between GDP and social health has been described by Professor Clyde Hertzman, Director of the Human Early Learning Partnership (HELP), at the University of British Columbia.  ‘Modernity’s Paradox’ is the title of the first chapter in this vitally important book edited by Keating and Hertzman entitled Developmental Health and the Wealth of Nations.²⁸ They begin by highlighting another mystery factor in modern society; the paradoxical association between wealth generation and the substantial threats to children and youth. They refer to the famous psychologist, the late Urie Bronfenbrenner, who testified in 1969 to a U.S. congressional committee about the troubling scientific evidence that pointed to a societal breakdown in the process of “making human beings human”. He said,

The signs of this breakdown are seen in the growing rates of alienation, apathy, rebellion, delinquency and violence we have observed in youth in this nation in recent decades.

Many years later in 1996 he observed the situation had worsened and said

Today they have reached a critical stage that is much more difficult to re­verse. The main reason is that forces of disarray, increasingly being generated in the larger society, have been producing growing chaos in the lives of children and youth.

Despite the multiple components of the Social Health Index, it tells an important story that is validated by other measures to indicate that many children and young people in the United States are in trouble. Evidence of this is found using the Child Behaviour Checklist developed by Dr Achenbach in the sixties. He reported that since 1974, problems have become significantly worse for American children in general with negative feelings such as apathy, sadness and various forms of distress have increased.²⁵

Similar to PSM, but with a focus on children, the term childhood psychosocial dysfunction, was considered a ‘new morbidity’ when described by the father of community paediatrics, Dr Haggerty, in the seventies. In the preface to his book he said,

Health is affected by environmental and social processes as well as by biological factors. The community in which a child lives is a major determinant of health. Although such statements are widely accepted today, they are not reflected in our health care institutions.” ²⁰

It is questionable how much influence his evidence and suggestions were made in urging health care systems to respond to the new morbidity when childhood psychosocial dysfunction has become widely acknowledged as the most common, chronic condition of children and adolescents - and a problem that is growing.^29,30  Studies have found that 12-25% of all American school-age children and 13% of preschoolers have an emotional and/or behavioural disorder ^{25, 31, 32, 33} and a substantial number are not being identified or treated.²⁴ As well as the impact on future prosects for the children, the cost implications in both the short and long term are significant and influenced by how the health systems respond – if at all.²⁷

In the US, where it is not a requirement to have a specialist referral from their GP, paediatricians have long been an important first resource for parents who are worried about their children’s behavioural problems.  But paediatricians do not receive adequate training concerning psychosocial problems,³⁴ are hesitant to attach potentially deleterious labels to children,³⁵ do not have time during office visits to address psychosocial needs, and may have limited access to mental health referral networks.³⁶ But studies estimate that only about 50% of these children are identified by their primary care physicians and that once identified, only a fraction of these children receive appropriate health care.^{37, 38.}

It is hard to imagine that in countries where general practitioners are the primary service providers to children, that psychosocial issues are better managed than in countries where paediatricians are the primary provider. Either way, the growing burden of PSM amongst children is not considered in forward estimates of healthcare costs. Also PSM in childhood increases the risk of costly health problems in adolescence. A National College Health Risk Behaviour Survey explored the association between thinking about suicide (suicide ideation) and injury-related behaviours among 18- to 24-year-old college students. Students who had occasional thoughts that life was not worth living were more likely than their peers without such negative thoughts were more likely to carry a weapon; engage in a physical fight; boat or swim after drinking alcohol; ride with a driver who had been drinking alcohol; drive after drinking alcohol, and rarely or never used seat belts.³⁹ These surveys are repeated regularly and the trend is that these risky health behaviours, in a relatively advantaged population, are increasing.⁴⁰ 

The relationships between suicidal ideation or attempts and family environment, subject characteristics, and various risk behaviours were also examined among 1,285 randomly selected children and adolescents, aged 9 through 17 years, of whom 42 (3.3%) had attempted suicide and 67 (5.2%) had expressed suicidal ideation only. Low parental monitoring and risk behaviours (such as smoking, physical fighting, alcohol intoxication, and sexual activity) were found to be independently associated with increased risk of suicidal ideation and attempts, even after adjusting for the presence of psychiatric disorder and sociodemographic variables.⁴¹

Children would be more resilient to these problems if they began school with the social and emotional competencies to succeed. Unfortunately it appears that there is a growing trend in the wrong direction. In his extensive review of time trends in psychosocial disorders of British young people, Sir Michael Rutter, Britain’s first child psychiatrist found evidence of increasing problems and supported the view that there has been an increase in depressive conditions among the young.⁴²  He has also been quoted as saying, “Most, if not all, forms of serious mental disorder may be associated with difficulties in or distortions of parenting.”⁴³

Estimating whether childhood psychosocial issues are increasing globally is difficult because measurements in most countries are plagued by problems with defining whether a child or young person has a significant psychosocial issue or not, and how this information is collected, if at all, is variable. This has contributed to limited progress in understanding child psychosocial ‘disorders’.⁴⁴ It is recognised, however, that low income is strongly associated with PSM in children⁴⁵ and in an Australian survey, the researchers found a higher proportion of mental health problems among children living in step/blended or sole parent families, and with parents who had left school at an earlier age.⁴⁶

Children, especially younger children, with PSM use health services more. As they get older their use of health services reduces but costs are higher as they have greater need for psychiatric care.²⁷ The longer term impact of PSM is difficult to assess due to the problems of its recognition as indicated above but a study has shown more evidence of the link between more severe PSM and ill health later.⁴¹ This was demonstrated in a large study of 17 thousand Americans who were exposed to adverse experiences as children. The Adverse Childhood Experiences (ACE) Study poses the question of whether, and how, childhood experiences affect adult health decades later. This question is being answered with the ongoing collaboration of Drs Robert F. Anda at the Centre for Disease Control (CDC) and Vincent J. Felitti of Kaiser Permanente’s Department of Preventive Medicine in San Diego, California. Kaiser Permanente is multispecialty, prepaid, private health insurance system.

An ACE score is calculated from indicating whether one of more of the following events occurred in childhood:

Recurrent physical abuse

Recurrent emotional abuse

Contact sexual abuse

An alcohol and/or drug abuser in the household

An incarcerated household member

Someone who is chronically depressed, mentally ill, institutionalized, or suicidal

Mother is treated violently

One or no parents

• Emotional or physical neglect

Almost two-thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs. The higher the ACE scores the higher the risk of the following health problems:

• Alcoholism and alcohol abuse
• Chronic obstructive pulmonary disease (COPD)
• Depression
• Foetal death
• Health-related quality of life
• Illicit drug use
• Ischemic heart disease (IHD)
• Liver disease
• Risk for intimate partner violence
• Multiple sexual partners
• Sexually transmitted infectious (STIs)
• Smoking
• Suicide attempts
• Unintended pregnancies
• Early initiation of smoking
• Early initiation of sexual activity
• Adolescent pregnancy

Clearly there are enormous implications from the ACE Study with more discoveries ahead as further research is conducted. Meanwhile it has helped to unravel more about the mystery factor as exemplified in the following pyramid constructed by the ACE team

The pyramid depicts how the ACE study was designed to explore whether adverse experiences in childhood can lead to ill health and premature death. Already it has emerged that risk factors, such as smoking, alcohol abuse, and sexual behaviours lead to diseases that are associated with one another. Consistent with the concept of syndemics; people with one risk factor also tended to have one or more other risk factors clustered together.

The two arrows linking adverse childhood experiences to risk factors are areas that need further research to confirm what is intuitive; that adverse experiences in childhood lead to negative health and social consequences higher up the pyramid. The ACE study was designed to help answer the question: “If risk factors for disease, disability, and early mortality are not randomly distributed, what influences precede the adoption or development of them?” Answers to this question, will inform new and more effective prevention programs. Meanwhile other discoveries are drawing attention to the importance of the early years in determining health or causing ill health that we will explore in the next chapter.

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The impact of the program has been studies extensively and results showed that parental care of the child improved and verified reports of child abuse and neglect over the next 15 years were reduced including injuries and ingestions associated with child abuse and neglect. There were fewer subsequent pregnancies, greater work force participation, and reduced use of public assistance and food stamps. The benefits of the Nurse-Family Partnership program have generally been found to be strongest for those women who were poor and unmarried at registration.¹⁸ This translates to a return on the $7000 of about $41,000 per child of low-income, unmarried, nurse-visited mothers and about $9000 per child of lower-risk nurse-visited mothers.¹⁹

Programs to promote child health are more effective the earlier they are implemented so it is feasible that if they commence prior to conception they could be even more cost effective. A good example has been provided already with the prevention of neural tube defects by supplementing the diet with folic acid.

The evidence, ranging from the population perspective through to the molecular level, is compelling that before and during the early years should be prioritised as this is when there is the greatest potential to achieve gains in future health and productivity. This contrasts to the adult population where interventions are difficult and expensive, as discussed in the previous chapter. Despite the evidence and logic to invest in the early years, the expenditure on health, education, income support and social services increases with age in inverse proportion to the potential for long term benefit. This is diagrammatically shown by Dr Bruce Perry, Provincial Medical Director in Children’s Mental Health for the Alberta Mental Health Board.²⁰ His estimation is backed up by a study that calculated that about a third of US health care resources are expended in the last year of life.²¹  Without a major increase or reallocation of health care resources to earlier in the lifespan the greater will be the need to spend more in the last year of life – a no win situation.  At some stage the plug has to be pulled on this mismatch between opportunity and investment but we will revisit this need in Chapter 10 after we have considered ways to get this point. 

* Head Start

10

The climb to health actualisation

Maslow's famous hierarchy of needs is often demonstrated by a pyramid, with the largest and most fundamental levels of physical needs for survival such as food, water, shelter etc at the bottom and the next few layers such as self esteem, friendship and love and security facilitating the rise to ‘self actualisation’ at the top. The problem with this model is that it fits individualistic societies but does not suit those raised in collectivist societies.  This parallels the distinction between clinical medicine that focuses on the health of individuals as opposed to public health that should focus on the health of populations.

Incidentally it is interesting to note that the selfishness of self actualisation appears to be a health hazard. According to a study of 150 heart patients published in the journal Psychosomatic Medicine many years ago it was found that those who talked about themselves at length or used more first-person pronouns had more severe heart disease and did worse on treadmill tests.¹ More recently there is evidence summarised in a book by David Hamilton that ‘doing good’ is good for your health.² Even watching a video of someone doing good increases the release of the beneficial salivary immunoglobulin A: the so-called ‘Mother Teresa’ effect.³

If Maslow’s concept of self actualisation is less selfishly applied to populations I suggest using the term; health actualisation.

 The mountain path to achieving this aspiration is smooth for some but may be too steep for others leading to a health gradient as demonstrated in the diagram based on one in the  WHO document, ‘Making partners: intersectoral action for health’.

When the factors that influence the gradient of the slope are favourable, the steepness of the slope is less, thereby making it easier to achieve health actualisation. This was predicted in a UK report by statistician and banker, Sir Derrick Wanless in his report commissioned by the British government in 2002.⁴

He noted that public health interventions may have different effects on different groups in society, due to their levels of knowledge and/or their resources. Some groups may be more responsive than others. This in turn means that some 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 and in so doing aggravating the Inverse Care Law. Wanless was asked to produce an action plan from his original report and in it he demonstrated that he is one of the few analysts to suggest that (using the overflowing bath analogy), turning off the tap is an idea worth considering. Wanless began his follow up report with the observation that if everyone was healthy, then the demand for health care would be lessened. He developed a series of projections of future health expenditure based on the prospect of the UK fully adopting his suggested policies to promote health and achieve the best use of health-care resources. He estimated that the UK would save £30 billion (US$48 billion) by 2022–23, representing about 40% of the total UK National Health Service (NHS) budget in 2002. However he acknowledged that “health inequalities are stubborn, persistent and difficult to change” and were widening “and will continue to do so unless we do things differently.”²⁹ It is assumed that things were not done differently as demand for health care services increased in 2009 prompting the director of the NHS Confederation’s Primary Care Trust Network to say that “This level of growth is unsustainable. The NHS will go bankrupt.” ³¹Also the health gap between rich and poor grew in line with the income gap⁵ and programs to reduce socioeconomic inequalities in the UK were ineffective. ³³ So what’s missing?

It’s the economy, stupid.

It’s the economy, and the obsession with its growth, that’s getting in the way of health and, ironically, wealth for all.

Ask a health practitioner to define ‘growth’ and it is likely that a reference to cancer will be made. The strategy to buy our way out of the global financial crisis was to stimulate consumption and yet this term has connotations of tuberculosis, a disease that is in decline but resurfacing due to multi-drug resistance.   But there is more for health practitioners to be uncomfortable about when implementing economic strategies. For example the widely practiced doctrine of economic rationalism,  

supports the application of economic principles to the formulation of public policy … It reflects the dominant influences of narrow economic theory and concepts in areas of public and social policy where broader social aims and objectives are paramount, and reduces all spheres of public (and private) activity to a monetary calculus in which those things which cannot be so measured are not measured at all.⁶

As we discovered in Chapter 4, health is difficult to define and impossible to measure so it puts it at risk in an economic rationalist environment. This was well summarised by Mathers and Douglas who said,

What is called the Health Care System concentrates almost exclusively on dealing with disease and trying to prevent death.  There are perfectly good reasons for this, but the lopsidedness of what are labelled health services must now be challenged.

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 well being 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.

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 well being 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 21^st 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 well being and sustainability may be contributing to the myth of a community’s aggregate wealth is synonymous with its well being.  That premise could be utterly false.⁷

200 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 in the late sixties;

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 tragically assassinated Robert Kennedy referred to GNP, which adds the total capital gains from overseas investment minus the income earned from foreign nationals to Gross Domestic Product (GDP). The GDP is the estimates the value of the total worth of a country’s production and services calculated over one year. From his quotation it is likely that Kennedy would agree with Richard Eckersley in his book, Measuring Progress: Is Life Getting Better? in which he refers to the GDP, and other growth indicators, as an inadequate measure of progress. He called for a new paradigm and made reference to many sources to support his argument such as American ‘economic physicist’ and ‘industrial ecologist’ Robert U. Ayres* who said in 1996 that,

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.

That same year the United Nations Development Program declared that,

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.

A year later, in 1997, the Organisation for Economic Co-operation and Development (OECD) High Level Advisory Group predicted that

Over the coming decades, economic growth will not be sustainable without serious attention to related environmental and social issues.

Despite these warnings and pronouncements economic growth continues as inexorably as it has since the 50s as a major objective of most governments and it is invariably an election issue with each party vying for votes as to who will outperform the other in stimulating the economy, increasing job opportunities, raising living standards, boosting business confidence and achieving a higher GDP. It is a formula that has worked for decades so why shouldn’t it continue? As indicated above, it cannot continue sustainably unless it is modified in accord with suggestions made by Philip Lawn, a senior lecturer in ecological economics at Flinders University. He suggests (1) as long as the net benefits of growth are equitably distributed, everyone is rendered better off; and (2) to be experiencing economic growth, the economy must be physically smaller than its maximum sustainable scale (i.e., be at a physical scale that is biophysically sustainable.⁸

Meanwhile there are limits to patience for the equitable distribution of dividends from growth as demonstrated by the Occupy Wall Street movement who no longer tolerate “the greed and corruption of the 1%.” Also the riots in England in the summer of 2011 were not just ‘criminality, pure and simple’ as described by British PM David Cameron.⁹ According to a report commissioned by him and the opposition leader it was concluded that the riots were fuelled by people 'bumping along the bottom', unable to change their lives with a lack of opportunities for young people, poor parenting, a failure of the justice system to rehabilitate offenders and materialism. Half the recorded offences in the riots were for looting, often of high-value products, including designer clothes, trainers, mobile phones and computers. The report called for young people to be protected from excessive marketing and to increase children's resilience to advertising. It recommended the appointment of an independent champion to manage a dialogue between big brands and government.

This recommendation was made 21 years after it was recognised that ‘increased materialism at all levels in society’ caused people to live beyond their means leading to stress from financial pressures. This was identified as one of many demand factors in Professor Holman’s review of Community and Child Health Services that we learnt in Chapter 6. He also blamed unrealistic media images for contributing significantly to this problem that subsequently became labelled as ‘affluenza’ - a painful, contagious, socially transmitted condition of overload, debt and anxiety that results from efforts to keep up with the Joneses. ¹⁰

Whilst economic growth and prosperity has contributed to health enormously in the past¹¹ this only applies up to a certain level. Similarly the sense of well-being in society increases up to middle income levels but then rapidly levels off such that extra income produces diminishing returns for average levels of well-being. The side effects of ‘excessive’ economic growth threatens health through its impact on sustainability, the diseases of overconsumption and inequalities. Possibly of greater impact, but hard to prove, is that by making and maintaining economic growth as the dominant priority over all else, including health, prevents the development and implementation of actions and strategies that are health enhancing. In summary, blindly following the axiomatic belief that economic growth is the raison d’etre of society has become a health hazard. As indicated by Professor Hanlon and Dr McCartney, “if you were setting out to create health, you would not choose economic growth as your vehicle.”¹² However, as discussed previously (p….), there is evidence to support the reverse; health is a vehicle to achieve economic growth.

To reach health actualisation there is the need to ensure that the right balance is achieved between a healthy economy and a healthy population. The evidence is clear that the two have been going more out of synch since around the seventies. In chapter 6 we saw how the social health index diverged down away and inverse proportion to GDP causing modernity’s paradox. A similar relationship is apparent   with the Genuine Progress Indicator¹³ demonstrating that, not only is wellbeing a casualty of increasing GDP, but so also is the cost to the environment and damage to many aspects of what makes life worth while.  It is this negative relationship that is causing economists to question the wisdom of maintaining economic growth and to even suggest that ‘degrowth’ is necessary.¹⁴ From my perspective as a doctor this seems logical because if you have a cancerous growth, making cuts is a commonly used treatment.

It is no coincidence that it was also in the early 1970s when there was a massive increase in the quantity of refined carbohydrates and fats in the food supply in the US associated with a parallel increase in available calories, increase in GDP and the onset of the obesity epidemic. This led Professor Boyd Swinburn and his colleges to postulate that a flipping point occurred in the early 1970s when the energy balance changed in most high-income countries as indicated in their graph constructed using data from the US.

Food availability for the USA, 1910—200658

From http://www.thelancet.com/journals/lancet/article/PIIS0140673611608131/images?imageId=gr3&sectionType=green&hasDownloadImagesLink=true

As a result of obesity some children will die before their parents and many will have the additional burden of also being worse off than their parents.³⁵ Adding to these potential woes in the US is the fact that it is the only industrialised nation where young people currently are less likely than members of their parents’ generation to be high-school graduates.¹⁵ In October 2011, PricewaterhouseCoopers published a report that revealed the prospect of intergenerational inequality¹⁶ with stark differences in the economic fortunes of people with similar career paths and life histories from different generations.¹⁷ Student debt, unaffordable housing and low pensions is the legacy handed down by the early 1960s ‘baby boomers’ to the generation of students that are at the age to enter University. These students, born in the early 1990s, or Generation Z, could be about 25% less wealthy at age 65 than the baby boomers in terms of their access to housing, pension and other financial wealth. And with less wealth, less health will follow thereby further aggravating Peak Health.refer Colin Butler’s paper (economy)

It is not surprising that young people are anxious about their future. A 2012 United Nations report of e-discussions with young people around the globe revealed that they are concerned about many issues but in particular they are worried about the quality and relevance of their education as they perceive a mismatch between the training offered and the needs of the labour market.¹⁸

The Robert Johnson Foundation was similarly concerned when it realised that, for the first time in the history of the United States, it is raising a generation of children who may live sicker and shorter lives than their parents. As a result, in February 2008, the Foundation established a national, independent and nonpartisan Commission to raise awareness of the factors beyond medical care that affect a person’s health. The ‘Commission to Build a Healthier America’ spent a year researching and reviewing evidence, collected new data and listened to experts, leaders and citizens around the country. They produced a wealth of information to support their recommendations and these are contained in several reports that are available on their website www.commissionhealth.org

A key finding was that people with more education are more likely to live longer, to experience better health outcomes and to practice health-promoting behaviour such as exercising regularly, refraining from smoking, and obtaining timely health care check-ups and screenings. Higher education is also associated with living in low Broken Window Index suburbs that are less stressful, have stores with affordable healthy foods and with access to recreational facilities. Living in such health –promoting suburbs facilitates the adoption of healthy behaviours that are passed on to the next generation as babies of more-educated mothers are less likely to die before their first birthdays, and children of more-educated parents experience better health.* And the reverse of all these facts is true.

Education is also associated with a greater sense of control, social standing and social support all of which influence health.  But determining which comes first is hard to ascertain. Does a greater sense of control, social standing and social support lead to greater educational achievement or does improved education encourage the greater perception of personal control, fostering skills, habits and attitudes—such as problem-solving, purposefulness, self-directedness, perseverance and confidence—that contribute to people’s expectations that their own actions and behaviours shape what happens to them? Either way a strategy to increase educational outcomes is extremely valuable from both a health and financial perspective. The evidence from a range of developed countries shows that an additional year of education reduces mortality rates (at all ages) by around 8 percent. Compounding the benefit of a further year of education is that this will also increase earnings by an average of about 11 percent, which also contributes to reduced mortality as demonstrated in the American National Longitudinal Mortality Study.³⁸ If uneducated Americans achieved a similar health status and longevity as their educated counterparts the potential gain is estimated to be $1 trillion.

In view of the clear association between education and health, the Commission developed an Education and Health Calculator whereby a comparison can be made between each American State in relation to each performs on their education levels and how this translates into their annual morality rates. By means of an online Education Slider the effect of altering education levels can be visualised in relation to death rates, State ranking and the number of averted deaths. It is a powerful resource and it is unfortunate that a similar tool is not available to assess the influence of health care interventions on death rates and averted deaths.

The Commission made the following recommendations to achieve a positive impact on the health of all Americans in years, not decades. These recommendations have potential applicability to any country that wants to improve the health of its citizens.

The ten recommendations are as follows:

1. Fund and design WIC and SNAP* (Food Stamps) programs to meet the needs of hungry families for nutritious food.
2. Create public-private partnerships to open and sustain full-service grocery stores in communities without access to healthful foods.
3. Feed children only healthy foods in schools.
4. Require all schools (K-12) to include time for all children to be physically active every day.
5. Become a smoke-free nation.  Eliminating smoking remains one of the most important contributions to longer, healthier lives.
6. Ensure that all children have high-quality early developmental support (child care, education and other services).  This will require committing substantial additional resources to meet the early developmental needs particularly of children in low-income families.
7. Create “healthy community” demonstrations to evaluate the effects of a full complement of health-promoting policies and programs.
8. Develop a “health impact” rating for housing and infrastructure projects that reflects the projected effects on community health and provides incentives for projects that earn the rating.
9. Integrate safety and wellness into every aspect of community life.
10. Ensure that decision-makers in all sectors have the evidence they need to build health into public and private policies and practices.

The Commission emphasised that the key to success in building a healthier nation is the need for substantial collaboration among leaders across all sectors, including leaders in child care, education, housing, urban planning and transportation – leaders who may not fully comprehend the importance of their roles in improving health.³⁶ This is consistent with the HiAP approach that is taking a while to become established in the US despite advocacy for its adoption by independent Public Health organisations.³⁸ In Europe, however, HiAP was formally legitimated as a European Union (EU) approach in 2006. However Dr Meri Koivusalo, Senior Researcher at National Institute for Health and Welfare in Finland, argues that HiAP remains more rhetoric than action. And he makes this observation in Finland where, as I mentioned earlier, the programs in North Kerala were held up as evidence of success of the HiAP approach. He also raised the issue, (that I have discussed in relation to the medical model) of not only the need for health in all policies, but also health in health policies.

The key problem, as Koivusalo sees it, is that, ‘…health systems and public health regulation are currently more under pressure from becoming subservient to the aims of other policies.’³⁹ And the most dominant in most governments is Treasury.

But Deaton proffers a possible solution to the fact that health and wellbeing is not the top priority of most governments. He suggests that policies should be framed in the light of wealth and health simultaneously. He uses smoking as an example of a "health inequalities" issue as smoking rates are higher among the poor and less-educated. Policies that increase taxation that are meant to punish tobacco companies results in the transfer of income from those who continue to smoke to people who would otherwise pay higher property and income taxes.  Deaton argues that the better policy is to tackle low incomes and poor education especially the latter as, “…more and better education improves both earnings and health, making it doubly attractive.”

This concept of a combined approach to health and wealth was also explored when countries in WHO's European region met in Tallinn, Estonia in June, 2008. They developed the following diagram to demonstrate the linking of health systems, health, and wealth in a mutually reinforcing virtuous circle.

They identified four ways by which health could increase economic growth; 1 - healthy people are more likely to be employed than those in poor health, with less sickness absence, and a lower probability of early retirement; 2 - when at work they are likely to be productive; 3 - because healthy people can expect to live for a long time, they might invest time and money in their education, itself a driver of economic growth; 4 - for the same reason, they can save much for retirement, providing money for capital investment.

Whilst the first two are supported by evidence, the last two have only been described in low-income countries. Nevertheless, the governments present at Tallinn believed that that the time had arrived to reconsider the view that health-care expenditure is a drain on wealth and to explore ways in which gains in health and wealth can become mutually reinforcing.

The conference not only called for greater spending on health systems but also for more targeted investment in evidence-based policies and interventions, and strengthening of both public health and health care, underpinned by a commitment to narrow the substantial inequalities that persist in many countries.¹⁹

These are worthy aims, but in the context of heath care budgets growing unsustainably it is impossible to expect a favourable response to a request to government spend more on health care based on a tentative promise that better returns can be expected than before. If I was a health minister I would tell the fund seeker to come back when…

Future of Medicine: Avoiding a Medical Meltdown. ²⁰ 

The ambitions of HiAP are also laudable but the key to success is that the highest level of government has to embrace the concept. This will then translate into all government departments and agencies, especially treasury, being mandated to integrate health into their policies, plans and programs. Unless there is long term bipartisan support for HiAP from national leaders, governance for health will remain just a nice notion.

To turn a broad concept into a more focused concrete strategy that is more saleable, prioritising policies that demonstrate evidence for the best return on investment is logical.

This is the subject of the last chapt

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* Robert U Ayers  U. Ayres, an American physicist applied the first law of thermodynamics to economics. The law states that energy can be transformed but cannot be created or destroyed. By applying the law to economics, the closed cyclic economic system leads to useful raw materials and energy having to ultimately leave the system and return to nature as waste.

* Cuba realised this several decades earlier and acted on it as previously described.

* SNAP and WIC is the Special Supplemental Nutrition Assistance Program for Women Infants and Children that is provided to low income families following a nutritional assessment.