Misappropriation or necessary contribution?

Andreu Segura

If we understand that health is not, as suggested by the Andrija Stampar definition adopted by the WHO in 1946, the mere absence of disease or insanity, but something else, whether it’s well-being as the aforementioned description affirms, it’s a reasonable ability to functional adaptation as René Dubos proposed, it’s easier to understand the importance of the so-called social determinants of health, among which health care is but one more.

These comments don’t imply any disregard for health care, given its ability to ease a good part of the disorders caused by diseases and, sometimes, to cure them definitively. Incidentally, insanity is, according to the dictionary, madness or mental disorder, a distinction that highlights the specificities of psychiatric pathology.

Health care services can also contribute to the protection and promotion of health through preventive interventions such as vaccinations or the control of certain risk factors. And in part, also, promoting healthy behaviours, although the ability of health care services to change the influence of the environment, housing, education, transportation or work in health is limited. And these factors, together with social cohesion, among others, powerfully determine the level of health of the population.

For this reason, equating well-being and health would be misappropriation, since it could imply, erroneously, that the health of people and the population depends substantially on health care services. Additionally, by promoting activities and interventions for which neither organizations nor health care professionals are especially competent, we distort health priorities. (1)

It’s true that, since time immemorial, good medicine has always advised us to lead a healthy life, a practice that Marc Lalonde's famous report on the health of Canadians contributed to institutionalize. Thus, the health care services have been assuming to intervene in this area, an activity that is easier for them to the extent that effective drugs are available in hypertension, dyslipidemia or osteoporosis. At the cost of medicalization not always appropriate.

But the point is, many risk factors are not amenable to pharmaceutical prophylaxis or advice, and when they are provided, they are also not efficient or fair. Although knowledge and information are necessary, they are not enough to modify behaviours. The conditions in which life takes place influences behaviours much more and often make them refractory to hygiene recommendations. Healthy modification of living conditions is an aim that far exceeds the possibilities of health care services.

This doesn’t mean that the health care services give up considering these determinants, among other reasons because health professionals suspect, detect, recognize and quantify the influence of these determinants. We must not invest in inefficient and inequitable efforts since some clinical initiatives for health promotion and protection are like pouring water into a leaky bucket. But above all, we need to encourage citizens' initiative, especially since health care services are often an obstacle to it. This is the core.

As Geoffrey Rose said and his disciple Michael Marmott has promoted, if the causes are social, the remedies must also be. So the role of health care services concerned in improving the health of the population is to contribute to this global political purpose, not to replace the role of other actors involved and probably not to lead them either, unless that there is no better alternative.

All of this comes from the recent publication by the King's Fund of the booklet A vision for population health. Towards a healthier future (2), a proposal based on the quantitative estimation of the influence of the most decisive social determinants of health, such as housing, environment, transport, education or work, on health and health care system in England, which has led it to classify, according to the degree of the evidence, the impact on health, the speed with which it’s achieved and the contribution to reducing inequities in interventions in each of these social determinants. Thus, for example, adequate schooling is one of the most beneficial and emphasized influences on health and it contributes significantly to the reduction of the most unfair inequalities although this influence takes time to materialize. In contrast, interventions that improve safe transportation have a rapid effect on health but don’t contribute as much to the reduction of unfairness as the attached table shows.

A proposal that also recognizes the importance of personal behaviours, the health care system and the community and social environment of people, which together with the aforementioned determinants, make up the columns on which the population's health is built. These pillars must be properly articulated if we would effectively promote and protect the health of the population. This requires designing a successful strategy and applying it promptly.

But while health reform plans and proposals emphasize purposes and guidelines, it’s less common for measurable objectives to be formulated and, rarer still, to mention the actions necessary to overcome the obstacles that hinder the development of healthy public policies that place health among the real priorities of governments and administrations, with an impact proportional to the gross domestic product dedicated to these objectives.

Hence the interest in the recommendations planned by the document, specifying the changes that, depending on the approach, should be addressed. The first notable change is that national and local political authorities should exercise the leadership because health policies go much further than health care policies. It also highlights the generalization of accountability, which, besides being a moral obligation, contributes to energizing the reform processes. And, last but not least, it’s the adequacy of the financing and, in particular, its adequate distribution so it should be efficient and equitable.

Bibliography

[1] Heath I. In defence of a National Sickness Service. BMJ 207; 334: 19. 

[2] Buck D, Baylis A, Dougall M, Robertson R. A vision for population health. Towards a healthier future. The Kings Fund: London 2018.