Monday, 18 April 2011

Better health, not greater wealth, should be society’s goal

Richard Eckersley

The rise in life expectancy, which more than doubled globally last century, is a cornerstone of human development. While there are competing theories about what produced the health gains, they can be, broadly speaking, attributed to factors such as material advances, especially better nutrition; public-health interventions such as sanitation; social modernisation, including education and social welfare; and improved medical treatment and care.

Historically, then, medicine and other health professions have been part of a broad, progressive movement that has improved not only life expectancy and health, but quality of life more broadly. The connection was close; the early emphasis in public health was on how social conditions influenced health and how they might be improved.

Today the relationship has changed. Health professions are increasingly engaged in countering the growing harm to health of adverse social trends, at least in developed nations. At the same time, however, they have become part of the problem because of a scientific emphasis on, and political advocacy of, a biomedical model of health based on individual cases of disease and their associated risk factors and treatments at the expense of a social model of disease prevention and health promotion. This has contributed to a separation of population health from social conditions, to the detriment of both.

Most public-health initiatives focus on individual risk factors associated with physical health: smoking, diet, exercise, alcohol use. From a health perspective, this emphasis neglects the importance of mental health; from a prevention perspective, it under-estimates the importance of social and environmental determinants.

Furthermore, the research on social determinants focuses on socio-economic factors, notably inequality, to the neglect of cultural factors such as excessive materialism and individualism. Culture and mental health are closely linked; both concern what people think and feel. This is seen clearly in young people’s health, an important predictor of future population health. Contrary to longer historic trends and official perceptions, young people's health has arguably declined over recent generations in developed nations because of rising obesity and mental illness.

Acknowledging the importance of culture and mental health highlights the social significance of health in two ways: by casting doubt on orthodox thinking on human development and national progress, which places Western nations at the leading edge; and by showing health is an important social dynamic, a cause not just a consequence of how well society is faring because it affects people in all their roles – as citizens, workers, students and parents.

The dominant biomedical perspective suits business and government. It is in biomedicine that profits are to be made, not in social health. This model also limits the political significance of health to the politics of healthcare services. This policy focus is challenging enough as governments struggle with rising demand and costs. However, the challenge is easy compared with trying to reconcile emerging health-based social realities with existing wealth-based political priorities. Embedded in the biomedical model is a hidden ideology that defends and promotes the status quo.

The scientific and political responses to the situation might include more research on public and mental health, especially transdisciplinary approaches that integrate epidemiological, sociological, psychological and anthropological concepts and evidence. Similarly, with health services and programs, the share of the health budget allocated to public health and mental health should be increased.

The response also needs to go beyond the health system to embrace, for example, rethinking the role and purpose of education, and greater regulation and control of business, especially advertising and marketing, the dominant promoters of an unhealthy, hyper-consumer culture.

However, the most important application of this perspective may be in the contribution it can make to a much broader political and public debate about the lives people want to lead, the societies they want to live in, and the futures they want to create. That debate is intensifying, but health plays only a limited part in it.

A broad view of population health and wellbeing and their social drivers – socio-economic, cultural and environmental - challenges the legitimacy of the dominant worldview of material progress (which gives priority to economic growth and a rising standard of living), and supports the alternative, sustainable development (which seeks to balance social, environmental and economic priorities to achieve a high, equitable and lasting quality of life).

The contest between the two models, or narratives, of progress has been framed largely in economic and environmental terms, and the social dimension has been neglected. Population-health research can help to correct this distortion.

This is an edited extract from:
Eckersley R. 2011. The science and politics of population health: giving health a greater role in public policy. WebmedCentral PUBLIC HEALTH 2011; 2(3):WMC001697.
The paper, and other papers, are available on Richard’s website:

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