Stepping outside of health to be healthy
I understand that AMA President Associate Professor Brian Owler, during his recent visit to the Northern Territory, had impressed upon him by health policy managers just how critical progress in the provision of mainstream medical and public health services has been to reducing rates of low birthweight babies and encouraging increments in life expectancy. That is good news.
A/Professor Owler’s informants, however, went on to say that future gains in health would probably come more from outside health, including through action in portfolios such as education and transport, private sector activity that would improve food quality and security, and through economic uplift and reduced unemployment.
A/Professor Owler, a neurosurgeon who appears on billboards in NSW urging people to drive safely and without excess speed to keep their brains intact, knows very well what the health people in NT were talking about. There is a dimension to health that leads us not only out of the ward, but out of the Health Department and the health portfolio into the tough real world beyond. Paradoxically, the better we become at administering medical care and achieving low tobacco smoking rates and 95 per cent immunization rates, the less there is that we, in health and medicine, can do directly to achieve a preventive goal. The architects and engineers of our fate are elsewhere.
Take diabetes as an example. Think about the way in which the availability of high-quality, affordable food varies among suburbs according to economic status. Tired workers in Sydney’s western suburbs retuning late after a full day’s work in the city centre may easily settle for high-fat, high-calorie food because they do not have the time or energy to prepare more nutritious meals. Takeaway food stores abound, as do liquor outlets. Fresh food stores do not.
The design of new suburbs, and the redesign of old ones, is a mixture of private and public enterprise. Planning authorities need to be aware that their decisions will influence the health of people – and not merely (though importantly) in relation to sanitation and clean water.
The structure of Government, with its multiple departments, is robust and has served us well in health, and there are many positive examples of interdepartmental activity at both State/Territory and federal level, often involving health and education. In South Australia, an active program of ‘health in all policies’ has sought to inculcate an awareness of health consequences, especially for non-communicable diseases, of what is decided in portfolios other than Health. It is a tough job to establish a common language across different government departments.
It is true that the buck for health decisions ultimately stops with the individual. He or she decides what they will eat and drink, and how much exercise they will take. But 40 years ago the English epidemiologist Geoffrey Rose made a compelling point. It is theoretically possible for a health-conscious person to go into a pub with his mates carrying a bag of carrots to eat while they drink. But it is a big ask, and not many of us have the willpower to that extent.
Even before Rose, people were drawing compelling links between social and economic circumstances and health.
More than 60 years ago a young doctor in Johannesburg, Mervyn Susser, began asking some very pointed questions about rates of disease and illness afflicting black South Africans.
As he later recalled, at the time medical schools only taught about illnesses afflicting white people – “what happened in the black population was a foreign land”.
His questioning mind eventually led Dr Susser – along with his equally committed wife Dr Zena Stein – to become giants in the field of epidemiology, helping establish proven methods for studying and treating disease.
As he put it, it was about improving public health “from the ground up”, determining who had diseases, and asking why.
Sadly, Dr Susser died on 14 August, aged 92, but his legacy is a much keener understanding of the importance of a multifaceted approach to studying and tackling disease.
We need, as a profession, to reflect on how our advocacy to those who determine our environment might be conducted.
Individual choice is conditioned by the environment. A person living in sub-Saharan Africa in poverty is in no position to make lifestyle choices, and nor are many of our people, to a lesser degree, in Australia today.
If we wish to carry the preventive agenda forward, we need to follow the lead of the Victorian Traffic Authority and the AMA President and make our messages about improved environments clearly heard. Health is everyone’s business and, as our colleagues in the NT tell us, the next steps are to be taken outside our immediate domain.