Smith Institute: Your Good Health
‘Healthy living’, the 2nd seminar in the Smith Institute’s series of seminars (9 November 2005).
The ‘Your Good Health’ series of seminars is based on the premise that we will all be living much longer in the future, which raises important social, economic and cultural issues. The remit of this, the second, seminar – ‘Healthy Living’ – was where and what are the interventions that can help with epidemic chronic disease (ECD). The seminar took the form of two talks – one from Professor Stig Pramming (Director, Oxford Health Alliance) and one from Professor Alan White (Professor of Men’s Health, Leeds Metropolitan University) – followed by a Q&A session. The seminar was conducted under Chatham House rules – the information below is drawn from the talks and the discussion, without attribution other than to the two speakers.
This seminar was co-sponsored by the Oxford Health Alliance and Novo Nordisk.
The seminar spearheaded the use of new terminology, ‘epidemic chronic disease’, to denote the diseases such as cardiovascular disease (CVD), diabetes, some cancers and some respiratory diseases, that are reaching epidemic proportions.
More information about the Smith Institute and the event series can be found at http://www.smith-institute.org.uk/.
Smith Institute’s introductory note
‘Chronic diseases, particularly cardiovascular disease, type 2 diabetes, cancer and chronic respiratory disease, account for more than 50% of all deaths worldwide. Tobacco use, poor diet and physical inactivity are amongst the major risk factors, yet there is only limited public health, financial, and policy support for programmes aimed at their prevention. With 1 in 5 children in the world now smoking, and 1 in 10 classified as overweight or obese, future prospects regarding CVD and type 2 diabetes are grim. There are also clear differences between men and women, not just related to sex-specific diseases such as prostate and cervical cancers, which have implications for the development of diabetes and heart disease and to susceptibility to autoimmune diseases such as MS. At the core, chronic disease prevention and health promotion require a shift in thinking and actions by government and diverse stakeholders. What is required is to help make the healthy choices become the easy choices. But in spite of numerous policy initiatives, policies in the UK have often been un-joined up, gender blind and have not succeeded in rebalancing health policy away from the short-term imperatives of health care. At this seminar we want to focus on the question of how to promote gender-sensitive, joined-up policies that promote the long-term behavioural changes necessary to develop a preventative healthcare system.’
Opinions expressed are those of participants: they do not necessarily reflect the views of OxHA.
The problem of chronic disease globally
According to the World Health Organisation’s recent report, Preventing Chronic Disease: A Vital Investment, 388 million people will die in the next 10 years of avoidable chronic diseases. According to a leading academic, ‘This epidemic is avoidable: we’re watching it happen… People simply aren’t taking responsibility … Together we could solve it.’
The WHO report lists 10 basic facts about chronic disease:
- Chronic disease is responsible for 60% of all deaths worldwide
- 80% of chronic disease deaths occur in low- and middle-income countries
- Almost half of chronic disease deaths occur in people under the age of 70
- Around the world, chronic disease affects women and men almost equally
- The major risk factors for chronic disease are an unhealthy diet, physical inactivity and tobacco use
- Without action, 17 million people will die prematurely this year from a chronic disease
- 1 billion adults are overweight – without action, this figure will surpass 1.5 billion by 2015
- 22 million children under five years old are overweight
- Tobacco use causes at least 5 million deaths each year
- If the major risk factors for chronic disease were eliminated, at least 80% of heart disease, stroke and type 2 diabetes would be prevented; and 40% of cancer would be prevented.
The epidemic is a particularly burgeoning problem in low- and middle-income countries – while the West has seen great success in reducing death rates from e.g. CVD (studies by Jim Fries from Stanford show that illness can be postponed by 8–12 years), this success is not yet being mirrored in developing countries. For example, although tobacco use is falling in the west, it is increasing elsewhere: 2 trillion cigarettes are smoked annually in China, and 70% of Chinese men are smokers.
The problem of chronic disease in the United Kingdom
As noted above, there have been falls in death rates in the United Kingdom from some chronic diseases – notably CVD. Liam Donaldson recently noted (at the OxHA Annual Meeting) that 60% of the fall in death rates is due to lifestyle change and 40% due to medical interventions. This underscores the need for preventive efforts.
A senior government official made the point that keeping people in work will be critical for the economic health of the country over the next 50 years – and that a healthy older population is necessary.
The question was raised as to whether it will in fact be more costly to keep people alive for longer – but research by David Canning at Harvard shows that greater health plus longevity increases GDP; and the last year of life is equally expensive at any age. The aim should be to add life to years, as well as years to life.
The importance of prevention
There was full agreement that further chronic disease preventive efforts are needed. Part of prevention should be investigating the way in which society creates a healthy – or toxic – environment.
We need to find ways to ensure that people change their lifestyles before they suffer their first ill-health event, such as a heart attack – often, and particularly among men, the tendency is to put off lifestyle changes (giving up smoking, losing weight) until after the disease is manifest.
To make the greatest change, we should focus not just on the high-risk groups, but at the significant contribution that can be made by encouraging small changes in behaviour of lower-risk groups. For example, Farley and Cohen (Prescription for a Healthy Nation) note that there is a 15% reduction in problems arising from hypertension if you take tablets; but there would be a 22% reduction if no one put salt on their food – a quite astonishing contribution.
Failures of health care
Even in the United Kingdom, which has taken steps in the right direction (e.g. the Wanless Report), we have a system of ‘sick care’ rather than ‘health care’. Professor Pramming noted that we are standing at a crossroads: continuing to fund the status quo of ‘sick care’, or thinking in a more holistic, long-term way, and addressing ‘health care’. This point was reiterated in the comment that the United Kingdom should be a ‘therapeutic’ state, with a department of health promotion.
One aspect in which the UK health-care system was seen to be falling short is in access to services. Men, in particular, may find it difficult to access health care (including preventive measures, such as health screening). Only 8% of men have flexitime as an option, and only 18% of men with children have any form of flexible working (in contrast to 70% of women with children). If men have to take a day off to work, they are not going to take the time to do so if nothing appears to be wrong.
Senior government figures noted the challenge for the NHS to move beyond a 9-to-5 culture and extend examinations outside working hours. It was noted that the forthcoming White Paper (details released 10 November) would include this issue.
There was some concern that there was too much focus on the role of doctors in the discussion, rather than other health-care professionals such as nurses, who often have more time for each individual patient. Given that during a doctors’ strike in San Francisco there was a net decrease of 40 deaths, access to doctors is clearly only one part of the health equation.
Moving beyond even the wider range of health-care professionals, individuals like Jamie Oliver can make at least as much of a difference to health. There is a need for a broad focus to make a difference in chronic disease prevention.
Leaders in chronic disease prevention
We seem to have forgotten that much of the epidemic is preventable – lifestyle and environmental factors play a crucial role… but who should take the lead in this is often unclear. Potential leaders include:
- heads of state: the issue of chronic disease is not yet in focus at this level;
- health ministries: often face inadequate capacity and budget;
- WHO: addresses chronic disease annually (i.e. 48 times) – but there is still a huge discrepancy between what has been said and what has been done. 5% of the WHO’s budget goes to chronic disease, even though it causes 60% of global mortality;
- academic health centres: chronic disease is not a priority – academics are not doing enough (there are exceptions, such as the Oxford Centre of Diabetes, Endocrinology and Metabolism);
- research institutions: chronic disease research is not funded in proportion to the magnitude of the problem;
- international donors: money tends to go towards HIV/AIDS (and, to some extent, tobacco-cessation projects) – this distorts the health issues in the developing world;
- World Bank, regional banks: there has been no increase in funding for chronic disease;
- public–private partnerships: again, the partnerships all focus on infectious diseases, rather than ECD;
- global NGOs: there has been no support for the ECD agenda, to date;
- media: have shown little interest, and the messages are confusing and contradictory – for example, articles on health are next to adverts for junk foods;
- research journals: the coverage of chronic disease in research journals is not in proportion to the size of the problem;
- pharmaceutical industry: can have a major contribution in ECD.
Health in the workplace
As we spend much of our time – 37% of our waking hours for around 40 years – in the workplace, employers can make a difference by creating a environment at work that encourages healthy behaviour. In the United Kingdom, there have been major health and safety successes in reducing accidents (a reduction of 70% in fatal injuries over 30 years), but there is still much that could be done about wellness in the workplace: 30 million working days are lost annually due to ill health. Professor Pramming also noted the lack of rules concerning some important aspects of the working environment – such as hours that can be spent per day sitting at a computer. For employers to take action on health, there have to be clear incentives or benefits to employers – without these short-term benefits, the cost-effectiveness of investing in health may not be obvious.
However, there are examples of proactivity by business. Professor White noted that British Telecom has introduced an innovative web-based weight-loss campaign, to which 15,000 of its 90,000 employees have signed up.
Understanding of health in the workplace also needs to be improved. Professor White noted that workers may still regard occupational health departments as an arm of the management – which will deter them from seeking help, for fear of losing their jobs. One aspect of health in the workplace – stress – was a cause of concern. In today’s culture of long hours and increasing retirement age, the thought of working 48+ hours each week to the age of 70+ can be a source of significant stress. Also, men’s mental wellbeing can mask issues such as violence against women.
The discussion noted that mental health, including stress, had not been sufficiently tackled in the seminar – but it is the subject of the next Smith Institute seminar in the series.
The role of government
There was discussion about the role of regulation in preventing chronic disease. Regulation in areas such as seatbelt use has been highly effective – Professor White noted that any regulation that could be seen as being the actions of a ‘nanny state’ must be transparent, with the reasoning behind it clearly explained. Regulation helps us to manage our lives in a risky world. Particular comment was made concerning the role of government in alcohol legislation – the culture in the United Kingdom is different from that of the continent, and that 24-hour drinking by our young people will have serious health effects.
Regulation need not always involve wielding a stick – there could be legal, economic incentives to make healthy food cheaper, for example (i.e. wield a carrot). However, Professor Pramming noted that such changes would only work in partnership with citizens and corporations.
As an example of the effect that regulation (or the lack of it) can have, a leading academic noted that in 1970, Denmark and Sweden had the same life expectancy, but that Denmark’s decision to follow a deregulatory approach since that time has seen life expectancy fall relative to Sweden. (Professor Pramming commented that part of this fall is due to Danish women having taken up smoking in greater numbers.)
Differential approaches to health between the sexes and different social groups
Targeted ways to change lifestyle are important – for example, by tapping into the male competitive spirit in a way that the men know they can achieve. There was a concern that certain disadvantaged groups could continue to fall through the net – for example, the discussion on changing the working environment will have no effect on those not at work – whether unemployed, single-parent families, or self-employed/piecework workers. Women are key to health globally, and probably also in the United Kingdom – women as mothers have a particularly important effect on the lifestyle of their children. However, women are increasingly working, drinking and smoking – and will suffer the consequent health effects unless action is taken.
To some extent the seminar was preaching to the converted – there was a general consensus that input from many sectors is needed to make a difference to ECD. The health-care system must become more flexible and broad-ranging, and speak to everyone in a language that is appropriate and accessible.