At a recent talk about our book Too Much Medicine, Not Enough Health, I was given a note about a recent issue of the American Journal of Public Health that addressed the inadequacies of current public health education practices. This is an important issue: how to enable people to make health and medical decisions informed by good science. It’s the work Layna and I do on this show, in our practice, and in our book.
In an introductory comment, a researcher observed that “[f]rom 2003 to 2008, the American Journal of Public Health published 100 research papers about programs and policies that were found to significantly improve health…. Unfortunately, history tells us that few of these promising programs will be used outside a research setting.”
What answer did the editors have to this problem? Better marketing.
You see, public health institutions must learn from automobile and soft drink manufacturers in not only producing a quality product but also in getting that product into consumers’ hands, stomachs, and heads. I’m not kidding. On the face of it, this solution seems appalling. But it also gives us an insight into public health institutions: it has always been about handing down institutionally sanctioned health information to civilians.
However, learning from commercial marketing and distribution is only one way to solve the problem of building health knowledge. An alternative pioneered under the name “the diffusion of innovation” also looks at how technology and knowledge spread through a population. For me, the fundamental problem with the “market” solution is what public health officials are selling: instructions on how to be healthy created and disseminated from the top down.
This perspective is what we call in our book the culture of expertise. We know what’s good for you—that’s the product. What we have to figure out is how to sell it to you—by treating you as a consumer.
Fortunately, this view does not exclude other perspectives from the American Journal of Public Health. Last month, it published an article that compared the effect of several conditions in reducing the number of healthy years a person lives. First on the list, people who live in poverty have 8.2 fewer healthy years than those living out of poverty. Second, smokers have 6.6 fewer healthy years. Third, high school dropouts have 5.1 fewer healthy years. Being African-American was fourth, being obese fifth, a binge drinker sixth, and uninsured seventh.
Note that what the researchers were measuring was not life expectancy, but the quality of life remaining—measured by such things as how much and what kind of medical care you need. In other words, “healthy years” measures how many years you suffer before you die.
If this is true, what public health product are public health institutions failing to sell? That being poor is bad for your health so snap out of it?
I remember vividly from the film Unnatural Causes the Louisville, Kentucky physician who is leading community groups saying to them “I’m not here to tell you to eat more fruits and vegetables. I’m here to empower you.”
Last Friday, The Marmot Review to Reduce Health Inequalities in England was presented at a conference in London. The Review was lead by Michael Marmot, a pioneer in the field of social epidemiology and the social determinants of health who also appears in Unnatural Causes. In 2008, he was commissioned by England’s Secretary of State for Health to evaluate current research on and policy options for reducing inequalities in health.
The Review makes the following points. Reducing health inequalities is a matter of fairness and social justice. There is a social gradient in health—the lower a person’s social position, the worse his or her health. Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health. Economic growth is not the most important measure of a country’s success—the fair distribution of health, well-being, and sustainability is. Reducing health inequalities requires action on six policy objectives: give every child the best start in life; enable all children, young people, and adults to maximize their capabilities and have control over their lives; create fair employment and good work for everyone; ensure a healthy standard of living for everyone; create and develop healthy and sustainable places and communities; and strengthen the role and impact of ill health prevention.
Of course, the Marmot Review isn’t the official policy of the UK. That’s because institutions such as the UK’s Ministry of Health and the US Center for Disease Control and Prevention are first and foremost political organizations that exist to ensure social stability, not to ensure our well-being. So it makes perfect sense why their public health product is evidence-based information and not empowerment to control our lives. It’s not their job.
For his report Michael Marmot chose this epigram: “Rise up with me against the organization of misery.”
It’s taken from Pablo Neruda’s poem “The Flag.” The full stanza from which it is taken is this:
But rise up,
you, rise up,
but rise up with me
and let us go off together
to fight face to face
against the devil’s webs,
against the system that distributes hunger,
against the organization of misery.
Please sell me that public health product.