Better Health For All

• By Dr Stephen Dorey and Dr Joanna Nurse

Prevention and public health don’t actually save money, you still have to pay for another illness later on. Even if prevention does save money it takes so long to see outcomes that it’s can’t be a priority right now.

Variations on these two statements, sadly all too commonly expressed, by ministers of health and other policy makers were the drivers for a new publication by the World Health Organisation’s regional office for Europe and developed with the support of FPH. ‘The case for investing in public health ’ attempts to dispel these myths in a format accessible to decision makers.

This publication supports WHO Euro’s policy framework, Health 2020, which seeks to support a wide range of actions that can improve health. A component of Health 2020 is the European Action Plan for Strengthening Public Health Capacities and Services, which is structured around the 10 essential public health operations (EPHOs). The ‘Case for investing in public health’ specifically supports the strengthening and delivery of EPHO 8: Assuring sustainable organizational structures and financing.

Many governments have responded to the global economic crisis by reducing budgets. As the second largest area of public expenditure for most countries, health is in the financial spotlight. At the same time, there is upward pressure from the rising costs of technologies and pharmaceuticals and, to a lesser extent, from demographic changes, most notably our ageing populations. Austerity policies themselves provide an additional upward pressure from ill health associated with rising unemployment and, for those still in employment, increased job insecurity combined with wages that fail to keep pace with inflation.

This publication describes the economic and health benefits for individuals and governments of a public health approach by setting out the costs of failing to address current public health challenges. It then provides evidence of the cost–effectiveness of public health and prevention approaches across all levels of prevention including the wider determinants of health, resilience, health behaviours, risk factors, vaccination and screening. It includes the recommendations from WHO’s study of the costs of scaling up action to prevent and reduce the impact of non-communicable diseases (NCDs) and identifies those preventive interventions that show evidence for early returns on investment, not just longer-term gains.

The current costs of ill health are significant for governments in Europe: trends indicate we are headed down an unsustainable path of ever increased cost unless cost-effective policies are put in place.
•    Ageing populations with higher rates of NCDs have increased demand, while health care costs have generally increased.
•    The costs of health inequalities – the total welfare loss across 25 European countries – are estimated at 9.4% of gross domestic product or €980 billion.
•    Cardiovascular disease and cancer cost the countries of the European Union €169 billion and €124 billion respectively each year.
•    Tobacco use reduces overall national incomes by up to 3.6%.
•    Air pollution from road traffic costs the countries of the EU €25 billion, while road traffic injuries cost €153 billion each year.
•    Obesity accounts for 1–3% of total health expenditure in most countries; physical inactivity costs up to €300 per European inhabitant per year.
•    Mental illness costs the economy £110 billion per year in the United Kingdom

Some of these health costs could be avoided by shifting investment to prevent harm and increase activity in health improvement, disease prevention and health protection. Funding for public health and prevention remains a small proportion of overall health spending, despite potentially representing excellent value for money, with gains in the short and the long term, and savings for both healthcare and wider sectors of society. European governments currently spend an average of only 2.8% of their health sector budgets on prevention .

The economic justification is clear. The trend for steadily rising health and social care costs, as well as the costs of inaction, show an unsustainable situation. There is good evidence to support an expanded role for health improvement and disease prevention to increase value for money and, for some approaches, to go further and actually create a return on investments for health and other sectors, as well as potentially promoting an increase in wider economic productivity.

Many of these cost-effective interventions can also help to reduce inequalities. For example, those addressing mental health and violence prevention, which are issues disproportionately affecting population groups already suffering from adverse effects of health inequality. Investing in upstream population-based prevention is more effective at reducing health inequalities than funding more downstream approaches .

The publication provides examples of economic evidence for interventions in different areas relating to health. This illustrates the cost of inaction or “business as usual” and then outlines the cost–effectiveness of interventions. The evidence shows that a wide range of preventive approaches can be cost-effective, including interventions that address the environmental and social determinants of health, build resilience and promote healthy behaviours, as well as vaccination and screening.

Examples of prevention interventions that can give returns on investment within 1–2 years are provided and include the areas of: mental health promotion, violence prevention, healthy employment, road traffic injury prevention, promotion of physical activity, housing insulation as well as some vaccinations.

The evidence presented demonstrates the potential benefits of cost-effective prevention, using whole-system approaches and inter-sectoral partnership working. It shows that public health can be part of the solution. This is presented in an accessible format with short quick to read text and explanatory diagrams to encourage its use beyond the traditional public health world and help provide a tool for advocates in countries where public health may not be as strong as here in the UK.

This short video presents the key messages featuring international public health experts including a former president of FPH:

References

1) The case for investing in public health. Copenhagen: WHO Regional Office for Europe. 2015. (accessed 3 July 2015)
2) Health 2020: the European policy for health and well-being. Copenhagen: WHO Regional Office for Europe. 2012 (accessed 3 July 2015).
3) European Action Plan for Strengthening Public Health Capacities and Services. Copenhagen: WHO Regional Office for Europe. 2012 (accessed 3 July 2015).
4) Scaling up action against NCDs: How much will it cost? WHO report 2011 Copenhagen: WHO Regional Office for Europe (accessed 3 July 2015).
5) Global health expenditure database. Geneva: World Health Organization (accessed 3 July 2015).
6) Orton LC et al, (2011). Prioritising public health: a qualitative study of decision making to reduce health inequalities. BMC Public Health.11:821.

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• By Dr. Trevor Hancock
• Professor and Senior Scholar
• School of Public Health and Social Policy
• University of Victoria
• British Columbia, Canada

Key points

• We need to be more assertive in stating that public health is by far the most complex, challenging, interesting and holistic specialty in the health sector.
• Public health is really a branch of human ecology, concerned with the health implications of the interactions of our culture and society with the built and natural environments.
• Not only are we highly urbanised, we spend the vast majority of our time indoors, so the built environment, as a setting where the physical and the social interact, is a large factor in determining our health.
• Nonetheless, we live 100 percent of the time within natural ecosystems on a small planet, and these natural systems – which are in decline – are the ultimate determinant of our health.

First, my sincere thanks for the honour you are bestowing on me, There is no greater honour than to be recognised by one’s peers, especially in another country, and especially by such a respected body as FPH. I have worked in public health for over 35 years, and plan to keep going until they nail down the lid of my coffin. Along the way I have learned a few things I would like to share.

Public health – the most complex specialty of all

First, health is almost entirely different from health care and medicine. While I graduated in medicine (from Bart’s), I sometimes tell medical students that I later graduated from medicine to health – and in the process, I had to un-learn medicine.

While medicine – and indeed, all the healing professions – are a noble cause, I truly believe that public health is a higher calling! Surely there are few jobs more important than keeping people healthy, protecting them from harm and preventing them from become sick or injured in the first place or dying prematurely.

Moreover – and this is something we seldom say, and not loudly enough – public health is by far the most complex, intellectually challenging and exciting of all the health professions. I like to tell medical students that by comparison with public health, neurology or heart surgery or other medical specialties are comparatively simple. Because in public health we not only need to know the biological and clinical sciences and epidemiology, we need to know ecology, urban planning, sanitary engineering, architecture, anthropology, sociology, community psychology, policy, planning, administration, communications, education, politics and more.

We need to extol the virtue of the generalist, or more precisely, the holist. Like society as a whole, we have failed to recognise that generalism or holism are in fact specialties in their own right, as are those that practice these ways of thought and action. Here I include the practitioners of family medicine as well as public health practitioners.

In fact, the multiple, complex and interacting ecological and social threats to health that we face in the 21st century cannot be solved by specialists, but by holists, who can see and recognise the patterns, understand and act on and within complex adaptive eco-social systems.

Public health as human ecology

Public health is really a subset within the discipline of human ecology – which was once wonderfully defined as “the study of the issues which lie at the interacting point of environment and culture” (Dansereau, 1966). It was the incorporation of these concepts in my work – as well as the thinking of mentors such as Harding LeRiche and John Last, who both wrote books on public health and human ecology – that led me to develop the Mandala of Health: A Model of the Human Ecososytem – together with my close friend and colleague Fran Perkins in Toronto in the early 1980s in Toronto (Hancock and Perkins, 1985; Hancock, 1985).

The socio-ecological approach embodied in this model has been core to all my work in public health, and should be core to the practice of public health at any level. Thus while much of my work in the past 40 years or more has been focused on the natural and built environments, it is important to understand that they both are eco-social systems.

We are now past the point at which more than half of humanity is urban, and in high and even many middle-income countries, that figure is 80 or even 90 percent. Moreover, we in the high-income countries spend about 90 percent of our time indoors. So the built environment is in many ways our most important environment.

But our cities and communities are in fact settings (as are our homes, schools, workplaces, hospitals, prisons and so on), which means they are places where the physical and the social environments intersect and interact. In fact, human ecology in part grew out of an attempt to understand cities in the 1930s. So the creation of healthy cities is an eco-social challenge.

However, while we may spend almost all of our time in built environments, we still live 100 percent of our time on the Earth, and within global and regional natural ecosystems. Those ecosystems are in trouble, and the cause is human activity. It’s not just climate change, bad though that is.

It’s also depletion of resources, especially those related to food production such as agricultural land and water; mounting damage to the oceans, which further threatens food supplies; the pollution of entire ecosystems and food chains – and ourselves – with persistent organic pollutants and heavy metals and – as result of all these and other changes – the start of a sixth great extinction, this one caused by us.

We are passing planetary boundaries for ecosystem stability in several key areas. But when ecosystems decline or collapse, so too do the communities and societies embedded within and dependent upon them.

All of these ecological changes – which are so massive and so significant that geologists are have been considering declaring a new era, the Anthropocene – constitute a massive threat to the health of the population – which means they are a public health issue, on a mammoth scale.

Public health must now adopt an eco-social approach in addressing the health implications of ecological decline (just as we did in addressing the health implications of industrialisation in the 19th century) in its task of creating a more just, sustainable and healthy future.

Public Health in the Anthropocene: Addressing the ecological determinants of health

While we have paid great attention to the social determinants of health in recent years, which I agree is important work, we have largely ignored these ecological determinants of health. That is why I have spent the past three years leading a workgroup for the Canadian Public Health Association examining the ecological determinants of health and the public health implications of global ecological change (the CPHA Discussion paper) and the 100 page technical report.

In our report we make it clear that the ecological and the social intersect and interact. The massive and rapid ecological changes we are seeing are driven by major social and economic forces which are themselves driven by social and cultural values rooted in Western notions of ‘modernization’, progress, development and growth. However, these driving forces contain within them the seeds of their own destruction. Clearly, we have to address them as a single eco-social problem.

In the 19th century, we confronted the massive challenge of industrialisation and urbanisation, and together with our reformist allies in many other sectors, we faced and largely dealt with that challenge. Of course, cities are still a challenge, especially the rapidly growing cities of the low and middle-income countries, so there is still much work to be done.

For the past 40 years the environmental movement has been doing public health’s job. Now we need to step up to the plate. We need to once again become leading players and partners in a process of reform, this time to create a more just, sustainable and healthy future for all. To do so we need to address both the urban health challenges and the global ecological changes we face.

We must educate the next generation of public health professionals in the context of human ecology and systems thinking, so they can take an eco-social approach to these massive challenges. Above all, we must become activists and advocates for economic, social, cultural and political changes that take us away from our present unhealthy course and that help steer us towards the more just, sustainable and healthy future we must create for future generations.

That is my challenge to the public health profession and to FPH. I hope you take it up.

References:

Dansereau, P. (1966) 1st Commonwealth Human Ecology Council Conference, London.
Hancock, Trevor (1985) The mandala of health: a model of the human ecosystem Family and Community Health 8(3): 1-10.
Hancock, Trevor and Perkins, Fran (1985) The mandala of health: a conceptual model and teaching tool Health Education 24(1): 8-10.

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