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'We ainít seen nothiní yet'

By Bret Hart - posted Monday, 13 March 2006

Leonard Syme, Professor Emeritus of Epidemiology University of California, Berkeley” has said, “If we think our medical-care system is in trouble now, we ain't seen nothin' yet”. One of his suggested solutions is to develop better proactive strategies for preventing disease and promoting health, rather than waiting to fix problems after they occur.

This is a reminder of Joseph Mulins’ poem regarding The Ambulance in the Valley with its message that has been largely ignored for the last 111 years. While it would be folly to dispense with “the ambulance down in the valley”, it is also nonsensical to build additional hospitals or reorganise them “in the valley” in the hope it will address the increasing flow of patients - otherwise known as frequent flyers - hurtling over the cliff.

A double blind, randomised, placebo controlled, crossover trial is not required to prove that they would benefit from parachutes, but while this prevention strategy is worthwhile, it does not address the fact people need to be prevented from falling (or being pushed) over the cliff in the first place. A prevention fence not only needs to be built but it needs to be constructed in such a way it takes account of past flawed designs.


Professor Syme describes his experience with failed prevention efforts while Raphael claims that the focus on lifestyles and behaviour change is ineffective, particularly for those at greatest risk. In addition, these strategies “… divert public and governmental attention away from addressing the broader societal determinants of health”.

A study published in the British Medial Journal has added further weight to the evidence that adverse life conditions - not lifestyle choices - are the main contributors to obesity, heart disease and diabetes.

In the UK Wanless Report (pdf file 137KB)it was noted that public health interventions may have different effects on different groups in society, due to their levels of knowledge or their resources. Some groups may be more responsive than others. This in turn means that some public health programs may improve general health, but also increase the gap between the health of the better off and the worse off.

This may also be true of health care interventions that may have differential take up by different social class groups. Existing socio-economic inequalities contribute to further health inequalities; and also contribute to establishing social norms that reduce the demand for healthy goods and services, hence providing little incentive to supply the local market directly.

A Lancet editorial referred to the “catastrophic” failure of public health to prevent contemporary threats to health as demonstrated by the unabated increase in obesity across industrialised nations. An Australian response to the challenging Lancet article precipitated some suggestions including the establishment of a Ministry of Public Health. However, as Wilson & McGeorge point out, a new ministry runs the risk of becoming yet another compartment within an existing non-integrated health care system.

So how should an effective fence be built? The first step in its design should be to analyse the factors responsible for determining the health of populations. These factors have only comparatively recently been identified. A good overview can be found in Canada where they have been exploring these fundamental and complex issues for longer than anywhere else in the world. The crux of the matter is summarised in one of the many wise quotes of the late Dr Geoffrey Rose: “The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social.”


Wilkinson and Marmot have provided ample evidence to support Rose’s assertion in their WHO publication, The Solid Facts (pdf file 474KB) and these facts have been a major influence on one of the few publications in Australia that refer to health inequalities.

So what’s the obvious remedy? “It’s the economy stupid!” Strong economic growth is perceived as the panacea for all societal ills. There has been sustained economic growth in most developed countries for decades, so is there evidence of a benefit to health? As health systems are concerned with the opposite (factors that have a detrimental effect on health) it is difficult to find much work on the primary determinants of disease.

There is, however, an Index of Social Health, developed by Fordham’s Institute for Innovation in Social Policy in the United States that combined federal government statistics: including infant mortality; child abuse; unemployment; average weekly wages; health care costs; youth suicide; high school completion; teenage births; violent crime; and affordable housing. They compared each annual measure with the year in which it was at its best level. In 1973 the Index stood at 77 points; by 1994 it reached its lowest level at 37. 

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About the Author

Dr Bret Hart a public health physician practicing in Western Australia.

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