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Medicine is a social science and politics is nothing else but medicine on a large scale
–Rudolf Virchow
In the West of Ireland, on the road from Galway to Clifden, there is a little town called Recess. Across the road from the local shop is a monument with the inscription: “On this site in 1897 nothing happened." The storekeeper is often asked by curious passers-by: “What was it that didn’t happen in 1897?" Professor Jack James, in his truly outstanding book, The Health of Populations: Beyond Medicine, highlights the conundrum of preventive healthcare as analogous to the non-event in Recess in 1897.
The problem is this: The enormous contributions of preventive healthcare, all the lives saved, go largely unnoticed. There is no event to celebrate, as nothing happens, but in this case the non-event is what we truly hope for – as we all truly hope to be healthy and well. But there is a major political and societal imbalance of perspective in the way we care for ourselves: we overrate the value of healthcare focused on proximal biological factors. Currently, 95–96% of healthcare spending in the UK and US is on biomedical treatments, with only 4–5% of budgets available for preventive healthcare. We get a very poor return on investment in this regard. For example, as noted by James, analysis of the reduction in death rate from coronary heart disease in the last decades of the 20th century in high-income countries indicates that risk factor reduction had a twofold greater life-saving effect than biomedical intervention. Unfortunately, our investment, governance, and collective approach to healthcare does not reflect a passion for prevention.
Saving lives and enhancing human health isn’t easy. Human psychology and human decision-making influence our healthcare policy thinking in profound ways. For example, as argued by James, it is difficult to feel anything more than abstract and ephemeral relief over tragedies that would have happened but did not, particularly when we are so deeply and frequently moved by tragedies that do happen. Reductions in the number of deaths associated with preventative measures is often reported in statistical terms, and the problem with these statistical reports, from a human perspective, is that they do not have an identifiable victim. James points to research highlighting that people care more about identifiable than statistical victims. The unfortunate consequences, says James, is that actions aimed at saving identifiable victims are more highly valued over actions intended to benefit victims who are no less real but are anonymous, even when the ‘anonymous’ group are far larger than the identifiable group. James suggests that future success in optimizing personal and population health may depend on overcoming this idiosyncrasy of human cognition.
At the same time, biomedicine somehow manages to dazzle and delude and keep us in a state of perpetual rapture and awe, when we should really be looking at the efficacy and effectiveness of biomedical interventions. The emotional, intuitive response can be difficult to overcome. I distinctly recall my first visit to the doctor. My older brothers and I had been playing in a local building site. One of my brothers threw a brick up at the wooden roof beams overhead, to see if he could break it. It bounced back at speed and hit my head. My brothers were nervous walking home to my father, as blood was pumping out of my head. My brother asked me, “What is 2 + 2?” To scare him, I jokingly answered: “3”. But my cognitive capacities were retained and I recall distinctly how the doctor stitched my head with great calm and humorous conversation. Without a local anaesthetic, he instructed me to dig my thumb nail into my index finger while he was stitching. I recall the experience of awe and respect. He did a good job. I recovered well and had great respect for doctors thereafter.
But regardless of any awe we may experience in our interactions with doctors and the biomedical establishment, James documents a vast body of evidence highlighting that the overall health of populations has never much depended on the knowledge and practices of physicians, hospitals, and biomedical research institutes.
Notably, almost all of the increase in human life expectancy during the whole of recorded history has occurred within the past 200 years. While the increase in life expectancy and the largescale reduction in mortality caused by acute communicable diseases over the past 200 years are often credited to innovations in medicine, evidence suggests that changes in the economic, social, and environmental conditions of people account for major health benefits observed. In the first chapter of his book, James pays homage to the work of Thomas McKeown. In his classic work, McKeown examined the decreasing death rates in England and Wales over a 200-year period from the mid-eighteenth century for a range of infectious diseases, including tuberculosis, typhoid, typhus, cholera, scarlet fever, whooping cough, and diphtheria. He found that most of the decrease in death rate occurred before practical medical interventions had been introduced.
So if it wasn’t medical practices and interventions that reduced mortality, what did? McKeown identified three main causes for the steep decline in infectious diseases and consequential improvements in health and life expectancy: (1) improved nutrition (i.e., reliable availability of quality food); (2) improved sanitation (i.e., provision of clean water and disposal of sewage), and (3) social innovations made possible by increased affluence (i.e., improvements in public education and literacy, improved standards of public and personal hygiene, and large-scale slum clearance and urban renewal projects). Similarly, as described by James, analyses of declining death rates in the U.S. from 1900 to 1970 associated with 11 major infectious diseases – typhoid, smallpox, scarlet fever, measles, whooping cough, diphtheria, influenza, TB, pneumonia, infections of the digestive system, and poliomyelitis – found that no more than 3.5% of the decrease in mortality could be attributed to medical intervention.
As reviewed by James, infectious and parasitic diseases continue to be the leading cause of death in only a small number of low-income countries, mostly in sub-Saharan Africa. The leading causes of death worldwide for both high-income and developing countries are non-communicable diseases, which account for over two-thirds of all deaths worldwide. With declines in infectious communicable diseases, in the period following World War II, as attention turned to non-communicable diseases, there was much optimism regarding the power of biomedical healthcare to eradicate major illnesses. However, James argues that this optimism was unwarranted, much like continued optimism in relation to the benefits of biomedical healthcare is unwarranted.
Notably, 90% of deaths from noncommunicable diseases are a result of five common diseases: cardiovascular diseases, cancers, chronic pulmonary diseases, digestive diseases, and diabetes. From a biomedical perspective, says James, in efforts to reduce mortality and morbidity and increase the health of populations, the medical establishment focus predominantly on the proximal biological causes of these diseases and thus spend most of the health budget (i.e., 95–96% in the UK and U.S) on treatments (e.g., surgical, pharmaceutical) that are proximal to the onset of disease. But James notes that non-communicable diseases develop over time and a medical focus on biological causes and treatments that are proximal to the onset of disease neglects the distal causes of disease and investment in the prevention of diseases. James reviews a mass of research evidence, across multiple chapters, which highlights that treating individual cases of disease has little impact on the population burden of disease. Furthermore, it often is of limited benefit even for individuals treated and there is often significant medical harm that results from failures of biological treatments. Conversely, whole-population risk factor reduction and investment in preventative interventions reduces the risk of disease for everyone, evidenced by increased health overall and fewer cases of manifest disease. As people live longer, James argues that population-wide expansion of morbidity from the failure of success of biomedical healthcare may be keeping many people alive in poor health. But there is an alternative: compression of morbidity, where people live longer and healthier lives. As convincingly argued by James, compression of morbidity is a more likely outcome of population-wide preventive healthcare, and is clearly the more preferred scenario for both humane and economic reasons.
The World Health Organisation (WHO) Health in All Policies Framework for Country Action, recognises that governments must contend with wide-ranging responsibilities that compete for priority and may sometimes conflict with population health objectives. The Framework highlights that the main determinants of personal and population health have environmental origins that lay mostly outside the direct influence of the healthcare sector in the personal, social, cultural, and economic lives of people. Population health is thus influenced by policies and decisions across all spheres of government. WHO, thus, asks governments to ‘health proof’ all government policies. The new focus is squarely on health promotion, specifically, enabling people to increase control over their health and its determinants, and thereby improve their health.
The work of the WHO parallels current efforts in international governance to move beyond measures of social progress and national wellbeing that focus exclusively on GDP, especially as the link between economic growth and wellbeing is not always positive. While debate continues in relation to the dimensions of people’s wellbeing that need to be taken into account and the emphasis to be placed on them, the discourse tends to include the following domains: economic resources, work and participation, relationships and care, community and environment, health, and democracy and values. There are important interdependencies between health outcomes and other aspects of wellbeing in this regard.
For example, as reviewed by James, historical and geographical analyses highlight how changing environments can influence the health of populations. In recent history, James points to evidence demonstrating that exit from the communist bloc was followed by immediate improvements in life expectancy in Poland, East Germany, and Czechoslovakia, indicating that the health of populations is profoundly influenced by social, economic, political, and cultural factors that influence ways of living. Cultural, social, and political factors can play out in specific policies that influence population health. For example, James notes that in Denmark, smoking is seen as an expression of individual freedom, whereas in Sweden smoking is controlled. Denmark has a death rate from lung cancer that is twice that of Sweden. National policies matter. James reports on research in the Netherlands, where, from 1970 – 2010, it has been found that health benefits from policies to promote population-wide risk factor reduction were three-times greater than benefits attributable to biomedical healthcare.
A focus on prevention and population health remains difficult for other reasons. James notes how special priority is often given to life-extending end-of-life treatments over other biomedical interventions, and by extension over preventive interventions. Allocating limited budgets involves setting priorities in light of the cost-effectiveness of treatments. James notes that the UK determines the cost effectiveness of interventions by reference to quality adjusted life years (QALYs), a metric that incorporates both length and quality of life. Using QALYs as a metric enables quantitative comparisons to be made between diverse health outcomes from diverse interventions for diverse conditions. However, some treatments may get preferential weightings, and these weightings are decided upon by the National Institute for Health and Clinical Excellence (NICE). James notes how, in response to both public pressure and industry lobbying, NICE recently decided to give extra preferential weight to the health gains from life-extending end-of-life treatments. This set a precedent for other lobby groups, and ultimately, it led to some patient groups receiving less preferential treatment. While preferential weightings may appear valid from the perspective of those in need, in light of the broader ethical problem of optimizing population health, the ethical basis for preferential weightings is often incoherent.
As highlighted by James, one of the most difficult challenges in healthcare is ensuring that attention to immediate urgent needs does not lead to neglect of needs that appear less urgent but are potentially more important. James notes the prevalence of cardiovascular diseases, cancers, chronic pulmonary diseases, digestive diseases, and diabetes are all linked with four major behavioural causal pathways: tobacco use, harmful alcohol and drug consumption, poor diet, and lack of physical activity. The prevalence of these behaviours is in turn influenced by the environment and the social activity that constitute and shape the environment within which people develop. Changing the environment and the individual and collective behaviour of people in the environment is the key to optimizing sustainable healthcare.
Some of the changes needed seem straightforward, but only if we focus our efforts and invest in changing our habitats and habits, says James. The evidence suggests that whole-population shifts in behaviour tend to be associated with changed social norms. Population-wide intervention that targets distal causes of disease is necessary for encouraging optimal personal and social dynamics leading to sustainable reductions in exposure to common risk factors. James reviews a massive body of evidence in this regard. For example, smoking cessation reduces the risk of myocardial infarction by as much as 50% within the first year after quitting, and within 15 years the risk of myocardial infarction is almost the same as in people who have never smoked. For lung cancer, the risk falls to 30–50% over 10 years compared to continuing smokers, and for those who quit before age 30 years, 90% of lifelong risk of lung cancer is removed. Also, the benefits of quitting smoking on survival post-myocardial infarction are greater than benefits of biomedical treatments.
Changes in diet can also have a profound effect on health. For example, consumption of fruit and vegetables can reduce the risk of hypertension, coronary heart disease, stroke, and cancer. As noted by James, the WHO program for 25% reduction in premature mortality includes specific dietary targets, including reduced intake of salt/sodium, saturated fatty acids and trans fatty acids, increased intake of fruit and vegetables, and regulatory action to restrict the marketing of food to children. Again, these may seem like straightforward changes that the biomedical establishment might simply take for granted. But given the range of foods available, many of which are unhealthy, considerable investment is needed to transform food production and marketing strategies and transform the dietary habitats and habits of the population, which is currently on a path to increased obesity and poor health as a result of poor dietary habits.
Similarly, while population reductions in alcohol and drug consumption and increased levels of physical activity have significant positive effects on population health, relative to biomedical healthcare spending, investment in interventions in this area is miniscule. The evidence clearly points to one conclusion, says James: continued reliance on biomedical healthcare will exacerbate the already worsening global epidemic of noncommunicable disease. As carefully documented by James, biomedical health is currently harmful and unsafe, has modest efficacy and disappointing effectiveness, and is unsustainable in terms of cost. Unfortunately, the dominance of biomedical healthcare, and the delusional optimistic beliefs driving biomedical science, are upheld by widespread industry entanglement with biomedicine. James reviews evidence showing that senior administrators and academic leaders within institutions frequently have personal financial interests in companies whose products and services are related to their institutional responsibilities. Entanglement of private and public interests has profoundly undermined the scientific integrity of biomedical research and development, and the whole practice of healthcare governance. Doctors, hospitals, and governments are incentivised to prioritize expensive biomedical interventions that are simply not effective in easing the global epidemic of noncommunicable disease. What is needed is a radical change of emphasis, away from a focus on profit to a focus on health itself. The evidence is incontrovertible, says James, susceptibility to disease and injury is determined more by behavioral and social determinants associated with ways of living than by any other factors. Therefore, the proper role for biomedicine is as an adjunct to risk factor reduction throughout the lifecourse.
As noted by James, the health behaviour of individuals as they develop is influenced by their family, friends and peer groups, school, workplace, and neighbourhood, which in turn are influenced by broader social determinants involving the activity of economic systems, education systems, broad social and cultural beliefs and practices, and local, national, and international political systems of governance and citizen empowerment. Viewed from this perspective, it is clear that biomedical practice constitutes a narrow range of the full range of activity influencing health. And given the changing demographics of the population, including significant population growth and population ageing, and the associated increase in the burden of disease, it has become increasingly clear that a radical shift in our social and political activity is needed to increase the health of populations in the long-term. We need a more expansive view, a long-term view, a balanced view on the causes of diseases, and a balanced investment in the prevention of disease. The narrow view on the proximal causes and the acute state of diseases as they arise results in imbalanced social and political activity and imbalanced investment in the current and future health of populations.
Jack James has written what can only be described as a masterpiece. Everyone interested in health should buy and read this book. I have not done justice to his book in my review, as it is so densely and finely argued that a comprehensive review would itself need to be book length. My sense is this book will be ranked in the top 10 best books written in the 21st century in the field of health sciences. A better book will only be written when the message in this book has been assimilated. If we can demonstrate that we can learn from experience and evidence and enhance the health of populations, then perhaps we can write another good book in the field of health sciences. Until then, we should focus on redesigning the political and societal activity system shaping our habitats and habits – we should get busy and work collectively to enhance the health of populations.
References
James, J. (2015). The Health of Populations: Beyond Medicine. Academic Press
