Opinion 'Big businesses will cry wolf and fire accusations of nanny-statism at any public health intervention'

HOW IS IT possible that the US spends more money on healthcare than any developed country but still has poorer outcomes?

Public health research can tell us a lot about this apparent paradox within the US healthcare system.

For starters, healthcare in the US is relatively expensive compared with other countries and is mostly delivered by private healthcare companies who extract enormous profits.

So, while this money may be considered health spending, much of it does not actually contribute to the cost of providing healthcare and keeping people healthy.

There is a massive wealth gap in the US and it has no system of universal healthcare.

Very rich people spend vast sums of money and benefit from expensive cutting-edge treatments, in hospitals akin to 5-star hotels, while poor people often struggle to access even basic community care services.

There is also evidence of widespread waste in the US health system, including overtreatment, which is related to the commercial nature of the system.

Public health research points to another reason for this incongruity between health spending and outcomes, and it lies beyond the healthcare sector entirely.

Health is not simply related to healthcare.

In fact, studies show that formal healthcare contributes to approximately 15% of the overall health of the population. 

(That is not insignificant; healthcare is vital when people get sick and this generally increases as the population ages.)

But we have to ask what constitutes the other 85% of factors that influence the health of the population?

According to research, they include behavioural patterns, genetic predisposition, social circumstances and environmental exposure.

The study of genetics is an evolving and ethically challenging field.

However, there is a strong body of evidence that the other factors – behavioural, social and environmental, can be addressed.

They largely concern the context in which we live, grow and work.

Behavioural causes of disease

How our own behaviour contributes to disease is a really interesting area that is contributing to the broader field of behavioural science.

Research shows that ‘nudge theory’ (which is when we implement measures that gently encourage people to change their behaviour) isn’t very effective at scale to address grand challenges, like obesity and climate change.

We’re beginning to understand human behaviour in terms of how we interact and are influenced by our environment rather than the simplistic idea of individuals choosing to make ‘good’ or ‘bad’ choices.

For example, we now know that commercial marketing techniques are designed to erode individual willpower, so unless healthy options significantly outweigh unhealthy ones, education alone cannot help people to ‘do the right thing’.

There is an abundance of academic literature on the most effective ways to influence behavioural change at scale and they largely relate to influencing the following: the physical environment (e.g. cycle lanes); the regulatory environment (e.g. clear food labelling and ‘no-fry zones’); the policy environment (e.g. health-proofing all policies); and the fiscal environment (e.g. taxes on cigarettes and sugary drinks).

These policies have been shown to have a much greater impact on the health of the overall population than approaches which focus solely on individual agency.

The leading causes of death in this country are cancer and heart disease, chronic diseases commonly referred to as ‘lifestyle diseases’, which is somewhat misleading.

These diseases are often preventable (not always) but only if the context and environment in which a person lives are supportive of living healthily. Otherwise, it is extremely difficult for an individual on his or her own to change their behaviour and sustain those changes.

Public health interventions at the household level and in settings such as schools and workplaces are also less effective than broader community and societal measures.

Social and environmental causes of disease

Health outcomes are inextricably linked to your economic status. People who live in wealthier neighbourhoods, attend good schools and have better-paid jobs, and job security, tend to have better health.

Needless to say, having a home is the most fundamental determinant of health.

When there are significant wealth disparities within a country, the overall health of the population worsens and Richard Wilkinson writes about this in detail in his book ‘The Spirit Level’.

We know that adopting population approaches to improving health can also do more to address health inequalities than individual level approaches.

We should remember that the largest increases in life expectancy over the last 100 years were down to public health measures, such as clean water, sanitation, tobacco control and vaccination – rather than healthcare.

Public health as a discipline has been overshadowed by advances in the biomedical sphere for decades.

Now that we’re facing an onslaught of preventable chronic diseases that we cannot cure with a pill (as with infectious diseases), it’s time that public health approaches are recognised and valued as the largest contributor to maintaining good health for longer.

Health researchers know that ‘we cannot treat our way out of cancer’.

The projections for cancer incidence alone could threaten the financial sustainability of our health system by the middle of this century.

Measures such as the workplace smoking ban (15 years old this week) and the recent Public Health (Alcohol) Bill are ‘upstream approaches’ in public health.

This means that instead of firefighting to save lives downstream, we change the focus to fostering and preserving good health now, preventing the illness from ever occurring.

We do this by tackling the causes of ill-health and the ‘causes of causes’.

For example, if obesity is a cause of cancer and diabetes, we try to reduce levels of obesity.

The big picture

Public health researchers study health systems and services, population health needs and inequalities, demographics, health statistics, disease patterns (epidemiology), causes of disease, and health promotion and protection.

Public health professionals can be medics, who work in the community, but they’re also statisticians, epidemiologists, environmental scientists, economists, policy analysts, sociologists, geographers and historians, or a mix of those.

According to the Institute of Medicine in the US: public health is “what we, as a society, do collectively to assure the conditions for people to be healthy”.

It is said that sickness is an inevitable part of ageing but there is a big difference between the general effects of ageing and premature onset of multiple preventable chronic diseases in your 50s or 60s.

If we are going to reduce the incidence of cancer, and other chronic diseases such as asthma and COPD, there are a few key things we need:

• Housing for all
• Easy access to healthy and affordable food
• Reduce dangerous levels of air pollution (particularly in cities)
• Clean water free from microbeads and other pollutants
• Local infrastructure to support active travel such as greenways
• Jobs that encourage physical movement
• Stronger regulation for industries that profit from causing ill-health – such as tobacco, alcohol and sugar.

The HSE was given a budget of €16 billion in 2019.

Health and wellbeing was allocated €121 million which works out as less than 0.001% of the overall budget.

Even though there are elements of public health in activities under other budget lines, this still gives a clear indication of how little we prioritise public health.

Big businesses will cry wolf and fire accusations of nanny-statism at any public health intervention.

But we need to look to the smoking ban, seat-belts and food labelling, as well as cycling infrastructure and firearm regulation (in the US) and ask, do they limit or increase our freedoms?

With our community groups and representatives, we can collectively demand the policies and regulation necessary to create healthy liveable environments.

This will help to relieve much of the pressure on our precious health system.  

Maebh Ní Fhallúin has a Masters in Public Health. She is a public health policy researcher and advisor with a background in media and communications.