Viewpoints |
Health needs more than health care: the need for a new paradigm
David J. HunterDurham University, Durham, UK
Correspondence: e-mail: d.j.hunter{at}durham.ac.uk
It is a significant time for health policy in Europe. There is a growing recognition in many countries that simply pouring resources into health care services, especially those centred on acute hospital care, cannot be equated with good health. Indeed, before too long such services will become unaffordable and unsustainable in terms of their public funding from social insurance or taxation unless efforts are made to manage demand and move health policy in a different direction. The so-called diseases of comfort—the primary cause of death in the 21st century and the next—demand a different approach.1
Current approaches to tackle these diseases, with their heavy reliance on a medical model and on the ethos of markets and consumerism, are doomed to fail. A new paradigm is urgently needed, based on a holistic conception of health and on creating the conditions for health. We need to identify assets rather than deficits and look for, and build upon, positive patterns of health. Working with people to create tipping points for change should become the focus of public-health leaders. Only in this way can people be reconnected with their health and become co-producers of it. In so doing, we can begin to transform sick societies into healthy ones.
The problem with the diseases of comfort does not lie principally in a lack of understanding. There is ample research and analysis testifying to the high levels of poor health evident in our societies and the extent of a widening health gap between social groups. There is also a sizeable body of evidence on what needs to be done about these failings, although there remain research gaps in our knowledge of what interventions work and are most effective. However, the chief impediment to secure sustainable change appears to lie in the absence of effective governance arrangements, coupled with the absence of political will to effect transformational change. Whether it is the obesity pandemic, growing alcohol misuse, the increase in mental ill-health or the widening health gap between rich and poor, society's efforts to deal with such complex public-policy challenges appear weak and inadequate. Too much emphasis is placed on changing individuals’ behaviour and on repairing the damage once it has occurred rather than on preventing it in the first place.
Running through the diseases of comfort is the role of human progress and civilization as contributing factors to the chronic disease epidemic. One view, favoured by politicians, maintains that human history is a record of continuous progress towards perfection. An alternative view, and reading of history, is that the search for perfection and the assumption of ‘progress’ are misplaced. Certain inventions and technological and other changes neither improve on the present nor represent progress. While we celebrate scientific knowledge alongside economic growth and productivity we should be aware of their impact on the poor, on work-life balance, on stress levels in the workforce and on lifestyles such as physical inactivity, poor diet, smoking and excessive alcohol consumption that could be, and indeed are, damaging to health. The modern myth is that science enables humanity to take charge of its collective destiny. But, as Gray has argued, ‘in truth there are only humans using the growing knowledge given them by science to pursue their conflicting ends’.2
Achieving good health and well-being is a multi-faceted and complex matter. For example, as the work of economist Richard Layard and others shows, health and happiness go together and both result in more productive and viable communities.3 Yet, despite the achievement of successful and growing economies it does not appear that these axiomatically lead to more contented, happier societies. Indeed, the evidence would suggest otherwise, especially in regard to people suffering from mild mental illness. Of course, some people thrive in the new flexible economy but whole groups in society are increasingly marginalized or living lives that are sub-optimal.4
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Despite growing recognition of the dilemma facing health policy, there is a governance problem at the heart of efforts to promote the public's health. Part of this lies in the nature of the public-health system itself which is large, diverse and without clear or fixed boundaries. But the issue is also a reflection of a preoccupation on the part of policy-makers and managers with acute health care services largely based in hospital. It is here, too, that the professional vested interests are at their most powerful and persuasive with the urgent forever driving out the important. The root of the problem lies in the nature of the return on investing in health. Much of the investment in public-health measures has a long-term impact and pay-off whereas in the modern age of instant gratification and quick fix solutions, there is no incentive to invest for the long term. Politicians operating within a framework of short-term electoral cycles are driven to achieve quick, visible results. So treating more people in hospital becomes a sine qua non of success in health policy. The fact that as societies we are in many ways getting unhealthier seems to have escaped the attention it deserves. Instead, we blame individuals for the lifestyle choices they make and leave virtually untouched the powerful interests, such as the global food and drink companies, that certainly shape, if not determine, those choices.
The Prussian pathologist turned anthropologist, Rudolf Virchow, was surely correct when he noted over a hundred years ago that ‘medicine is a social science, and politics is nothing more than medicine on a larger scale’. Almost every public institution and public-policy sphere has health implications, which is why the Finnish government when it held the EU Presidency in the second half of 2006 succeeded in getting the European Commission to adopt the concept of ‘Health in All Policies’ (HiAP). In its conclusions on HiAP, the Council of the EU calls
for broad societal action to tackle health determinants, in particular unhealthy diet, lack of physical activity, harmful use of alcohol, tobacco and psychosocial stress, since the individual capacity to control these determinants that account for major public-health problems, is strongly associated with broader social determinants of health, for example the level of education and available economic resources.5
HiAP has its antecedents in an ecological view of health, which emphasises that the contexts in which people live and the ways in which people relate to them are profoundly influenced by public policies. At a time when public policy is under threat from the neoliberal notion of the market state, HiAP is neither fashionable nor welcome in all quarters. If it is to survive it will have to be fought for.
Two related policy paradoxes are evident in all health systems and these cannot be ignored or overlooked. First, at the very same time that public health is high on the policy agenda in many countries, its capacity and capability to deliver remain weak and fragile. Public health, or its variants like health improvement and well-being, is not regarded as central to health policy or institutionalized in the way health care services are. We already know a great deal about the social determinants of health. Indeed, the WHO Commission on Social Determinants of Health makes the point that despite the vast majority of inequalities in health, between and within countries, being avoidable, action falls far short of what is required to tackle poor health among poor people and that the health gap is widening.6 While technical solutions within the health sector are important they are not sufficient. Dealing with the underlying causes and determinants of health may yield more significant and lasting gains.
Without over-exaggerating, the public-health problems we face—from obesity to the commercialization of childhood to environmental degradation—are outpacing the capacity of our institutions to change and meet the challenge posed. These, and the political systems they inhabit, have become ossified and incapable of effecting the type and scale of change needed. We struggle with institutions and systems that are no longer fit for purpose. Just as we have seen with the rise of terrorism and asymmetrical warfare which challenges conventional notions of war, our institutions have been overtaken by the pace of events and global scale of the health challenges we face. ‘More of the same’ is no solution.
Government does indeed have a key role to play in promoting health. The complaint is that it is in danger of abnegating its important and legitimate stewardship function. The notion of government offering strong leadership has given way to a more hands-off role conveyed by vacuous terms like ‘enabling’ and ‘facilitating’. But what is actually needed is more government engagement, not less, although not more of what we have now.
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If we are serious about building a broad-based public-health system in place of a narrow, rather reductionist and essentially biomedically centred health care one, then a good starting point is the US Institute of Medicine's definition of such a system.7 It
describes a complex network of individuals and organisations that have the potential to play critical roles in creating the conditions for health. They can act for health individually, but when they work together toward a health goal, they act as a system—a public health system.
In short, making the whole greater than the sum of the parts is the goal to which policy-makers should aspire. The problem is that many do indeed aspire to such a goal and are wholly sincere in doing so. Their rhetoric is also laudable. But all too often, that's all there is—nice words in abundance but no real commitment to action.
Central to the notion of a public-health system is the reference to ‘creating the conditions for health’. A problem with much public-health thinking and practice, especially that rooted in a medical model of illness and disease, is that it focuses on deficits rather than assets. Public health has tended to focus on identifying problems and needs of populations that require professional resources and high levels of dependence on health care and other services. Moreover, evidence-based public health is still dominated by a positivist biomedical approach to understanding ‘what works’. It therefore results in policy development which in turn focuses on the failure of individuals and local communities to avoid disease rather than their potential to create and sustain health. Deficit models have their place but the danger is that, coupled with the vested interests of those who subscribe to and actively promote such views, they dominate policy discourse to the neglect of asset models which have more to do with maintaining health.8
An assets approach to health directs attention to the resources individuals and communities have at their disposal which protect against negative-health outcomes and/or promote health status. These assets can be social, financial, physical, environmental or human resources (such as education, employment skills, supportive social networks and natural resources). They can promote self-esteem and reduce dependence on professional services which may in fact do little to promote such a positive health outlook.
The needs of the collective are not the same as the sum of individual preferences. The principal role of stewardship and governance is the protection of the population's health. This is, and will probably always be, an essential role for government but it must include intersectoral collaboration with the private sector and non-governmental organisations, and community involvement in decision-making and action. Collective responsibility and action should not be abandoned in favour of a focus on individual choice and consumer models of health promotion and prevention in which it is all a matter of giving people information and advice to allow them to exercise informed choice. The growing marketization of public policy in many countries threatens and weakens the stewardship role of government as the ties between individuals as citizens and the state become looser, more transactional and contingent, and replaced by individuals acting as consumers in a marketplace.
Health cannot be produced by a single sector or group of professionals working apart from the communities they serve. It has to be co-produced since it is by definition cross-sectoral and concerned with empowering communities either to take greater control of their health or to maintain those health assets which already exist within individuals and neighbourhoods. Despite governments in many countries acknowledging the need for joining up policy and management and working across organizational and professional boundaries both vertically and horizontally, the ability to succeed in these efforts has proved negligible. Introducing markets into health systems is unlikely to resolve the dilemma facing policy-makers and practitioners. Only strong and effective governments, working with and through the public, can determine what sort of ‘health society’ we want.9
But the public-health community needs to be more passionate about health issues. Its practitioners can no longer merely be dispassionate bystanders or analysts describing the problem. They need to become advocates for change working with the public to encourage them to seek change. People acting individually can do little to influence powerful multinational food and drink companies. But acting together, and putting pressure on government to act, can be a powerful force for change. That is why neo-liberalism, with its emphasis on individualism and choice, has narrowed the focus of public health and is antithetical to most of what it stands for.10
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This article is based on the 2007 G lecture given in Utrecht, The Netherlands in November 2007. The author is grateful to Johan Mackenbach for encouraging him to submit a version of the lecture for the Viewpoint feature.
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1 Choi BCK, Hunter DJ, Tsou W, Sainsbury P. Diseases of comfort: primary cause of death in the 22nd century. J Epidemiol Community Health (2005) 59:1030–4.
2 Gray J. Al Qaeda and what it means to be modern (2003) London: Faber and Faber.
3 Layard R. Happiness: Lessons from a new science (2005) London: Penguin Press.
4 Sennett R. The Corrosion of Character (1999) New York: Norton & Co.
5 Council of the European Union. Council conclusion on Health in All Policies (HiAP) (2006) Brussels: Council of the European Union.
6 World Health Organisation. Achieving Health Equity: from root causes to fair outcomes (2007) Geneva: WHO: Interim Statement. Commission on Social Determinants of Health.
7 Institute of Medicine. The future of the public's health in the 21st Century (2003) Washington: The National Academies Press.
8 Morgan A, Ziglio E. Revitalising the evidence base for public health: an assets model, Promot Educ (2007) XIV:(Suppl 2):17–22.[Medline]
9 Kickbusch I. Health governance: the health society. In: Health modernity: the role of theory in health promotion—McQueen D, Kickbusch I, et al, eds. (2007) New York: Springer.
10 McMichael T, Beaglehole R. The global context for public health. In: Global public health: a new era—Beaglehole R, ed. (2003) Oxford: Oxford University Press.
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