Drinking from the Waters of Prevention in Public Health

The Lancet’s recent editorial, ‘Austerity in Spain: time to loosen the grip’, argues that low government expenditure was ‘undermining the principle of universal coverage’ in that country. They point to pensioners devoting a substantial proportion of their incomes to medicines, and warn of excessive delays in elective surgeries being carried out. Detrimental effects are particularly evident among socially marginalised groups, such as migrants, they contend.

Yet in spite of these privations the authors note that life expectancy in Spain had reached 83 years in 2015, up from 79·3 years in 2000, the highest, on average, of any EU country. Unconvincingly, they assume the repercussions ‘of the financial crises are not necessarily all detrimental: ‘increases in healthy behaviours (eg, cycling, walking) and reductions in risky activities (eg, consumption of alcohol or tobacco) might occur’.

It is a common misconception that increasing health expenditure in any Western society will bring about a rise in life expectancy. In fact, there are rapidly diminishing returns on investment. Primary care, especially in maternity services and pediatrics (including selective use of antibiotics, and vaccination), certainly minimises premature deaths, but most healthcare addresses the symptoms rather than acting on the lifestyle triggers of the diseases that are now the greatest cause of mortality (and morbidity) in the Western world.

This reflects the Tudor-Hart Inverse Care Law, which states: ‘The availability of good medical care tends to vary inversely with the need for it in the population served. This … operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.’ In other words, efficiency declines as expenditure increases, and the freer the health market the worse the outcomes.

The two main causes of mortality in the Western world are cardiovascular disease and cancer. An early diagnosis may indeed nip a problem in the bud, but does not address the social and environmental drivers of these maladies. The hospital experience itself may even be unhealthy, as an expansive 2014 Swiss cost-benefit analysis of Mammogram services suggests. One in five of the cancers detected with mammography and treated was not a threat to the woman’s health, and did not require treatment such as chemotherapy, surgery or radiation.

In fact, the adverse effect of medical treatment is one of the leading causes of death in most developed countries: especially the high-spending United States, where in 2000 Dr. Barbara Starfield estimated:

• 12,000 deaths/year from unnecessary surgeries.
• 7,000 deaths/year from medication errors in hospitals.
• 20,000 deaths/year from other errors in hospitals.
• 80,000 deaths/year from nosocomial infections in hospitals.
• 106,000 deaths/year from nonerror, adverse effects of medications.

More recently in 2016, a John Hopkins team calculated that 250,000 deaths were caused by medical errors each year, making iatrogenic illness the third leading cause of death in the U.S., after cardiovascular disease and cancer. This serves as a particular warning to those countries converging with U.S. norms, where health care is largely left to market forces.

Yet health discourse continues to promote the scientific holy grail of the wonder cure, even for ailments intimately related to lifestyles and environmental factors. This approach may be traced to a Romantic era of science at the end of the eighteenth century, and has profound implication for government funding of health services.

Moreover, when a person is afflicted with serious a disease the demand for a cure becomes a matter of life and death. Most of us will do anything in our power to survive, crying from the rooftops if necessary. A healthy person, on the other hand, is generally oblivious or uninterested in why they remain hale and hearty. Stories focusing on the affordability of medicines or failures in health services have far greater news currency than the multifarious reasons why one society is less prone to disease than another.

A rational health system would continue to pursue medicinal breakthroughs, in collaboration with but not at the behest of the pharmaceutical industry, but place greater emphasis on addressing the complex aetiology of pathologies, in particular lifestyle and other factors that give rise to cancers and cardiovascular diseases.

II Lifestyle Factors

The advancement of lifestyle change, as opposed to dispensing medicines, would also require a cultural shift among the medical community, which could have revolutionary ramifications for society.

By and large doctors are trained to intervene against clearly defined pathologies, mainly through medication, and have less training in ‘soft’ psychological skills, which might alter self-destructive behaviours at source. Psychiatry, psychology’s close relative, is a specialised branch of medicine, overwhelming devoted to treating mental illness rather than providing guidance to society at large. Moreover, the complexity of lifestyle factors often renders research data unsatisfactory, with findings easily dismissed as conjecture or mere correlation.

Nonetheless, in a research paper this year entitled: ‘Impact of Healthy Lifestyle Factors on Life Expectancies in the US Population‘ researchers attempted to show that countering a range of unhealthy conditions including being a smoking, maintaining a high body mass index, taking little or no exercise, and consuming a poor diet and alcohol to excess, could significantly increase life expectancy:

The United States is one of the wealthiest nations worldwide, but Americans have a shorter life expectancy compared with residents of almost all other high-income countries, ranking 31st in the world for life expectancy at birth in 2015.3 In 2014, with a total health expenditure per capita of $9402,4 the United States was ranked first in the world for health expenditure as a percent of gross domestic product (17.1%). However, the US healthcare system has focused primarily on drug discoveries and disease treatment rather than prevention. Chronic diseases such as cardiovascular disease (CVD) and cancer are the commonest and costliest of all health problems but are largely preventable.

It is notable that the U.S. spends the highest proportion of its GDP on healthcare in the world, yet witnesses poor outcomes relative to other developed nations. This reflects the Tudor-Hart Inverse Care Law, which Obama’s Patient Care and Affordable Care Act (so-called Obamacare) redresses. Ironically, this is being whittled away by the Trump administration, who enjoyed support in the Presidential election from states where more than four out of five of those who rely on Obamacare reside.

Aside from insufficient access to Primary Care, the U.S.’s disease burden also arises from addictions to junk foods, drugs and cars. Medications or surgery do little to confront the obesity pandemic, or drug dependencies, including the opiate crisis which killed more than 33,000 thousand in 2015.

Rather than ramping up access to healthcare the authors instead recommend adherence to a ‘low-risk lifestyles, which could:

prolong life expectancy at age 50 years by 14.0 and 12.2 years in female and male US adults compared with individuals without any of the low-risk lifestyle factors. Our findings suggest that the gap in life expectancy between the United States and other developed countries could be narrowed by improving lifestyle factors.

The logic of this emphasis is consistent with the explanation of the authors of The Changing Body: Health, Nutrition and Human Development in the Western World since 1700 (Floud et al., Cambridge, 2011) for why average life expectancies have risen across the world over the past three centuries.

Crucial breakthroughs in raising global life expectancy arrived first in England in the late eighteenth century with government intervention in the grain market, which stabilised prices, thereby averting periodic famines. The average age at death climbed more dramatically once clean drinking water became available at the end of the nineteenth.

An important consequence of early-nineteenth-century urbanisation had been ‘the deterioration of the quality and quantity of the water supply(1)’. Drinking water only improved after substantial state-funded infrastructural investment in the 1890s. Thereafter, a range of water-born diseases like diarrhea, cholera and dysentery ceased to trouble the population to anywhere near the same extent.

The authors make a significant claim:

it would be easy to exaggerate the importance of scientific medicine when one considers that much of the decline in the mortality associated with infectious diseases predated the introduction of effective medical measures to deal with it(2).

They acknowledge that drugs like insulin, penicillin and prontosil as well as the mass immunizations of the post Second World War era made a difference, but maintain that adequate nutrition and clean water were the main determinants which overcame the infectious diseases which had carried off most of the population until that point.

III Smoking and Obesity

Today the drivers of disease in developed countries are manifold, but one factor often overlooked is the stress of living in perpetual income insecurity. This goes some way towards explaining why it tends to be the poor who make unwholesome food choices, especially favouring refined sugar, and continuing to smoke in spite of vivid health warnings.

Wolfgang Schivelbusch describes the ubiquity of smoking as a clear index of the state of civilisation: ‘If smoking is defined as an ersatz act which absorbs the increasing nervousness of civilized man, affecting the body’s chemistry as well as motor function, then this penetration of our culture by smoking demonstrates to what depth the culture is permeated by nervousness.(3)’

Moreover, the medical writer Kurt Pohlisch describes how: ‘In the act of smoking the nervously restless hand fixes on a purpose.’ He continues: ‘Smoking creates both a feeling of activity in leisure and one of leisure in the midst of activity … In terms of motoricity, pharmacology and sense psychology, smoking creates a cheerful mood, highly varied nuances of physical feelings, an agreeable stimulation with which to perform intellectual work, a pleasant sense of calm, a state of contentedness, satisfaction [and]easy cordiality.(4)’

Consequently, a substantial minority continue to smoke, despite constant and graphic advice to quit. What the campaigns against smoking fail to recognise is the role played by smoking – and the use of other drugs – in relieving the stress of living in perpetual income insecurity.

Similarly, sections of societies living under free market conditions are prone to unhealthy dietary patterns. Avner Offer asserts: ‘Among affluent societies, the highest prevalence of obesity is to be found in countries most strongly committed to market-liberal policy norms.’ He argues: ‘if stress generates obesity, then welfare states protect against stress, and are likely to have lower states of obesity.’

He says: ‘it is appropriate to think of the rise of obesity as an eruption, and to look for another eruption to explain it’. He identifies this as the emergence of the New Right in the late 1970s, and the market-liberal regimes that subsequently carried out their economic and social programmes in the main English-speaking countries, and elsewhere.

He argues ‘the economic benefits of flexible and open market liberalism, such as they are, may be offset by costs to personal welfare and public health, which are rarely taken into account’, citing the example of the UK where adult obesity has tripled since 1980. An obesogenic environment was actually largely in place by the 1970s: car-use and television-watching were well established, and food was already sugary, cheap and plentiful before Margaret Thatcher came to power. The same stress-inducing conditions emerged in the United States under Ronald Reagan.

Increased stress levels, especially fueled by employment uncertainty affect dietary choices: ‘Physiologically, stress leads individuals to prefer fatty and sweet foods, and frequently to consume more calories, exacerbating weight gain, especially in the form of risky abdominal fat.’ The idea of a link between insecurity, stress and obesity is supported by the ‘social gradient’ of obesity’: it is most prevalent among those at the bottom of the social ladder.

Illuminatingly, in the month after September 11th, sales of snack foods increased by more than 12% across the United States as paranoia, verging on hysteria, swept through the country. Overall: ‘among rich nations, the USA and Great Britain have experienced the greatest income inequality since 1980 and the greatest increase in the prevalence of obesity(3)’.

Peter Whybrow connects these responses to our early evolution. He argues that stress causes the lizard core of our brains to release dopamine, a hormone connected to pleasure, after consuming fatty and sweet food.

He paints a lurid picture: ‘In the presence of continuous psychosocial shocks, a complex work environment, repeated deadlines, a difficult marriage – the alarm bells are continuously ringing and the stress response is continuously in play. In consequences, the body is maintained in a high state of psychological arousal, where the vulnerability to chronic illness is increased, with obesity as no exception.(4)’

IV The Miracle Cure

Richard Holmes argues that several crucial misconceptions crystallized around the idea of science at the start of the nineteenth century, aspects of which continue to confound our understanding of public health.

There emerged at that point, ‘the dazzling idea of the solitary scientific ‘genius’, thirsting and reckless for knowledge, for its own sake and perhaps at any cost’. This is closely connected with the idea of the ‘Eureka’ moment: ‘the intuitive inspired instant of invention or discovery, for which no amount of preparation or preliminary analysis can really compare(5).’

Western medicine perpetuates what is essentially a mythology of invention, assuming genius will produce a wonder cure for diseases such as cancer; just as Edward Jenner developed the idea of vaccination for small pox by infecting a young farm boy with the disease after first giving him a dose of cowpox. He had learnt from local folklore that milk maids who developed that mild condition never contracted the deadly pox.

The chronic conditions we confront are not, however, susceptible to silver bullet breakthroughs in the form of drug interventions or vaccination. Medications may extend lives but generally fail to eliminate the diseases or address underlying causes. Nonetheless, the media is transfixed by tantalising cures lying on the horizon.

One notable exception is the long-standing campaign against smoking, but as indicated, governments fail to recognise why people refuse to give up. Meanwhile, we see desultory efforts to warn against or tax consumption of ‘pure, white and deadly’ refined sugar, or red and processed meat, categorised as possible and probable carcinogens by the WHO. Likewise the transport infrastructure of most developed countries is designed primarily for motor cars, leading to a serious lack of physical activity.

In the past doctors displayed greater awareness of the lifestyle factors that lead to disease, including the health benefits, or otherwise, derived from staple foodstuffs.

By the seventeenth century bread was a vital element in the diet of most Parisians, who, on average, ate a remarkable one kilo-and-a-half per day. At that the time the perceived adulteration of bread with ‘barm’ or yeast, as opposed to the traditional sourdough ‘levain’ method, produced a medical controversy, leading to the formation of an expert medical panel.

In condemning the use of yeast, the leading medical expert Gui Patin stated:

To say, as those who defend it do, that they have not seen anyone drop over sick or dead from eating this bread is not a good way to clear it of the faults with which it has been charged. It is like sugar refined with lime or alum, or heavily salted, peppered and sliced meats, or wines in which one tosses lime or fish glue, or other things bad in themselves which men concerned about their health avoid, even if none of these things causes death or threatens one’s health on the day it is ingested(6).

In spite of his advice the Paris parliament maintained a policy of laissez faire. The preference of bakeries for yeast is explained by it acting faster than levain. Since the arrival of the Chorleywood Process we have reached a point where most bread is no more than a junk food, which is surely a significant, slow-burning cause of disease. Indeed, the quality of a country’s bread may be an overlooked comparative indicator of its overall health.

The early nineteenth century radical doctor Thomas Beddoes defined the philanthropic doctor as ‘one who is humane in his conduct not so much from sudden impulses of passion as from a settled conviction of the miserly prevailing among mankind(7)’. Many doctors today display these qualities, but are often ground down by a system which processes disease. As specialisation increases compassion declines, with the body reduced to its composite parts. The pharmaceutical industry also increasingly distorts priorities, even in ostensibly publicly funded systems of healthcare.

As his career drew to a close, Beddoes made a number of simple proposals for raising public health: he suggested that all wives should be provided (free of charge) with anatomy lectures, washing machines (steam-powered), fresh vegetables and pressure cookers(8). These proposals would not be out of place today.

The emphasis of public health should shift to the general practitioner, whose role could be more educative (lessons in anatomy that Beddoes speaks of) than prescriptive, and the idea of general physician perhaps revived.

V The Wide Angle

‘The Second Battle of Moytura’ is the centrepiece of a ninth century Irish mythological cycle. It consists of a series of fantastical episodes of enduring interest. One such is the story of Nuada who loses his arm and authority in battle. We learn that the court physician Diancecht fashions him a prosthetic silver limb in its place.

In the meantime, Diancecht’s son Miach begins to heal Nuada’s real severed arm, but the father prefers his own methods and surgically kills his son by removing his brain. Miach is buried by his sister Airmed and from his grave sprout three hundred and sixty-five healing herbs, which she orders in her cloak. Diancecht has other ideas, however, scattering the herbs, each of whose value would remain obscure.

The possibilities of Miach’s more complimentary approach, rather than Diancecht’s artificial limb, suggests that healing may come from within the body itself, while the scattering of the healing herbs represents ignorance of the cures available in Nature.

Diancecht wish to preserve the dominance of his profession might serve as a metaphor for the approach of the pharmaceutical industry. Ben Goldacre’s Bad Pharma (London, 2012), in particular, has drawn attention to serious corruption in that industry. But medication will remain all-important as long as disease, not health, is the focus of public policy.

Human beings cannot expect to live forever, but serious reductions can be made to the burden of disease. We can address drug addictions, the quality of food and increase physical activity, but stress and low-level depression, lead to unhealthy lifestyle choices. If you take your meal in a car, as is the case with up to twenty per cent of those consumed in the U.S., it is more than a nutritional issue.

The culture of Spain is notable for its conviviality, although one could overstate how mealtimes are not rushed affairs, or that work can always be done manana. Nonetheless, the siesta is still respected, and the life-affirming fiesta an important dimension of civic life. However, the recent economic crisis, and current political turn, may be eroding aspects of this way of life. Moreover, the Mediterranean diet is no longer followed, and obesity increasingly apparent.

Notably, the generation in Spain enjoying such longevity today spent most of their working lives in a political system that protected industry from foreign competition, and, especially after the Socialists came to power at the end of Franco’s dictatorship, lived under a welfare state.

The generation at work in Spain today, or not as the case with so many, are subject to greater uncertainties in life than their parents, with potentially long-term health consequences. Indeed across Europe life expectancies have actually gone into decline for the first time since records began. This may reflect the stress induced by increasing income insecurity and inequality  in the era of the euro.

Altering any culture is slow work, but a rational view of public health should recognise a cultural dimension to most infirmities. A breakthrough in public health could be to see all medicine ‘as a branch of psychiatry, and psychiatry as a branch of philosophy’, as Iain McGilchrist put it.

We may also return to a more general appreciation of our reality that animated the first generation of scientists, including polymaths such as Alexander von Humboldt who wrote: ‘In this great chain of causes and effects no single fact can be considered in isolation.’

 

(1) Roderick Floud, Robert W. Fogel, Bernard Harris, and Sok Chul Hong The Changing Body: Health, Nutrition and Human Development in the Western World since 1700 (Cambridge, 2011), p.173

(2) Ibid, p.178

(3) Wolfgang Shivelbusch Tastes of Paradise: A Social History of Spices, Stimulants, and Intoxicants (New York, 1992) pp.96-111

(4) Ibid, pp.96-111

(5) Avner Offer, R ‘Time Urgency, Sleep Loss, and Obesity’ in Avner Offer, Rachel Pechey, and Stanley Ulijaszek, Insecurity, Inequality, and Obesity in Affluent Societies (London, 2012) pp.129-141

(5) Richard Holmes, The Age of Wonder: How the Romantic Generation Discovered the Beauty and Terror of Science (London, 2008) p. xvii

(6) Madeleine Ferrieres Sacred Cow Mad Cow (Translated by Jody Gladding) (New York, 2006), p.188

(7) Richard Holmes, The Age of Wonder: How the Romantic Generation Discovered the Beauty and Terror of Science (London, 2008) p.286

(8) Ibid, p.302