Steven Lewis, Marcel Saulnier, Marc Renaud. Handbook of Social Studies in Health and Medicine. Editor: Gary L Albrecht, Ray Fitzpatrick, Susan C Scrimshaw. Sage Publications, 2000.
Neither health nor health care ‘just happens.’ To be sure, nature is powerful and the best laid plans gang aft agley, but in developed societies—the context for this chapter—we have considerable latitude to alter our individual and collective states, if not our fates (for in the long run, as Keynes famously put it, we are all dead). Health issues are often at the centre of public debate because health is usually defined more as a public good than a market commodity (particularly outside the United States). As a result, health policy is a powerful instrument that can literally shape destinies.
The title of this chapter implies that health policy should be reconfigured, but that it is tricky business. The premise is that the determinants of health are complex, and producing health is not the same as providing health care to address illness. As our understanding of health deepens, we need to develop health policy responses to problems and issues that are consistent with what we know. Meeting this challenge successfully is made more difficult by its financial and political dimensions. To make sense of these realities, it is important to survey the landscape, identify the barriers to change, and point to opportunities for overcoming the inertia inherent in complex systems. Those are the tasks we have set ourselves. We begin with the known, describe obstacles to change, outline strategies for progress, and conclude with observations on community.
A Few Simple Truths about Health and Health Care
Public health and social welfare policy emerged mainly in the nineteenth century, but the reach of science remained comparatively limited well into the twentieth century. Particularly since the Second World War, health policy has become a major area of national public policy and economic activity. In this section, we make a number of observations about the experience of industrialized countries during this period, with a particular focus on health care, health promotion, and the so-called broader determinants of health. This sets the stage for a discussion of barriers and strategies to reconfiguring health policy in the following two sections.
Health Care: A Modern Preoccupation
The transformation of health policy from a focus on basic public health issues early in the twentieth century to its post-war emphasis on health-care services to individuals can be attributed to a number of factors: advances in medical science, entrenchment of individual rights and entitlements, greater attention to social security, increasing standard of living, and the rise of consumerism, to name only a few. Although data on health expenditures seldom go back farther than 30 or 40 years, it is reasonable to assume that in the early 1900s health spending accounted for a very modest share of national income, and public health outlays were likely as prominent as spending on personal health-care services. Today, health expenditure accounts for anywhere from 7 to 14 per cent of national income in industrialized countries, with an average of about 8 per cent. By far the lion’s share of spending is directed to personal health-care services.
Health-care systems are continuously evolving in response to various economic and social pressures, epidemiological patterns, and medical knowledge. The 1980s and 1990s have seen an unprecedented wave of structural reforms in many countries designed to improve the efficiency and effectiveness of health-care services. Amid this inconstant state of affairs, a number of ‘simple truths’ are emerging from the collective experience of industrialized countries that are highly relevant to the question of reconfiguring health policy.
Simple Truth No. 1: Health-Care Systems Want to Grow
Health-care systems have an inherent tendency towards expansion. The providers of services are often also consumers’ agents. Health care is both intrinsically valued, and instrumental to the achievement of a greater goal—better health—that all desire. However, because providers have historically held a virtual monopoly on knowledge, shrouded in the mystique of practice, supplier-induced demand plays a very important role in health care (Evans 1984). If left unchecked, there is no telling how large a share of national income health care would eventually consume. The United States, with roughly 14 per cent of its GDP devoted to health care, has set the high-water mark among industrialized countries—although President Clinton’s ill-fated first-term health reform plan envisioned further growth to 17 per cent by early in the new century. In most other countries, cost-containment efforts have limited health care outlays to less than 10 per cent of GDP (Brousselle 1998; Deber and Swan 1998; GRIS 1998); but it is a constant struggle.
At the root of this expansionist dynamic lies a potent interaction among the desires and expectations of recipients and producers of services. We all want to be cured of disease, cared for when we are ill, and live long, healthy lives. We therefore willingly allocate substantial resources to achieving these ends. However, the systems we have put in place to meet our healthcare needs—collectively the medical-industrial complex-are not mere instruments of our desires, to be enlarged or curtailed at will. They have become powerful political interests that pursue satisfaction of their own intrinsic needs. As long as there is illness, there will be public pressure to address it and to inject more resources. With so many expansionist forces afoot, governments face a very challenging environment in which to manage health-care resources effectively.
Simple Truth: No. 2: Higher Health Spending Does Not Necessarily Lead to Higher Health Status
In principle, there would be prima facie justification for a continuous growth in real health-care expenditure if the additional outlays could be shown to improve health status. However, beyond a certain threshold of expenditure, long since surpassed by most industrialized countries, one would be hard-pressed to conclude that spending more on health care leads to better health for a population (GRIS 1998). In fact, cross-national comparisons of expenditure and outcome reveal some rather puzzling patterns.
- Although there is great variation in levels of health-care expenditure, conventional health status indicators for most countries are concentrated within a very narrow band.
- In several cases, lower-spending countries have better health status than higher-spending countries. The Japan versus the United States example is the most obvious, but there are several other instances where this is true.
Simple Truth No. 3: Universal Access to Health Care Does Not Lead to Universally Good Health
Despite the enormous progress made over the last few decades in making medically necessary health care a basic entitlement, and despite significant gains in aggregate population health status, health disparities persist. Individuals who are wealthy and well-educated tend to be healthier than those who are poor and illiterate. Universal health care has done little to change the way health status is distributed across groups of the population.
One might argue that it is unreasonable to expect health care to fundamentally affect the distribution of health throughout society. After all, it deals with only a small fraction of the population at any given time, and usually comes into play after health problems have occurred. However, if the medical-industrial complex claimed only modest credit for improving population health status, formally recognized the preeminence of the socioeconomic, environmental, and other determinants of health, and otherwise acknowledged the limits of its impact, its ability to secure and retain an ever-increasing share of national wealth would be compromised.
Simple Truth No. 4: Public Awareness of Risks to Health Has Greatly Improved
The mid-century preoccupation with medical science gave rise, by the 1970s, to a renewed focus on individual risk factors and lifestyle choices. During the 1970s, many countries started turning their attention towards health promotion as a means of addressing the health disparities that universal health care could not tackle effectively. The impact of health care was limited, it was thought, because it was too ‘downstream.’ Hence the call for a more ‘upstream’ approach that would prevent health problems by targeting known risk factors such as diet, physical activity, substance abuse, and sexual behaviour, to name only a few (Canada. Health and Welfare Canada 1974).
Upstream approaches to health, of course, are not new; they were about all we had until recent times. The major breakthroughs of the nineteenth and the first half of the twentieth centuries were in public health: improvements in sanitary infrastructure, housing, nutrition and workplace conditions. These advances had widespread population-level effects, as did general improvements in living standards. Depending on whose version of history one favours, life expectancy increased as much as 20 years before the advent of modern and universally accessible medical care (Dubos 1965; McKeown 1979).
Perhaps the greatest contribution of health promotion over the past two decades has been to raise public awareness about individual risk factors. Few people today are ignorant of the dangers of smoking, drug abuse, driving while impaired, fatty diets, risky sexual behaviour, and sedentary living. Further, with some variability across countries due to cultural or political factors, the public is much more ready today to accept state interventions in the marketplace and even curtailment of individual freedoms in the name of protecting or advancing health. Examples of this are many: selective and punitive taxation levels on products deemed injurious to health (tobacco, alcohol); mandatory health warnings on cigarette packages; compulsory seatbelt legislation; and dramatic interventions in food production and distribution to prevent the spread of illnesses such as mad cow disease.
Simple Truth No. 5: Health Care Almost Always Wins Out in the Competition for Resources
In spite of a much greater public awareness of risks to health, there has been no major shift in the allocation of resources away from health care towards health promotion and disease prevention (Canadian Institute for Health Information 1997). This was true in both the 1970s and 1980s, an era of strong economic growth and favourable fiscal conditions, and today in the midst of prolonged fiscal restraint and moderate economic growth.
One intractable reality remains the political cost of shifting resources away from cure towards prevention and promotion. Virtually by definition, health promotion requires a different calculation of costs and benefits because it promises future, not immediate, gains and challenges the status quo. It is the enemy of complacency, the official voice of concern about the future, and a persistent reminder of the perils of our pleasures. In contrast, pouring more resources into health care generates short-term political capital because it responds to highly visible and viscerally felt needs, and expands the domain and security of providers. In addition, perceived motive counts, particularly where cynicism about politics runs high: even the most effective health promotion interventions will gain little public support if thought to be a smokescreen for reductions in health-care expenditure.
Simple Truth No. 6: Changing the Distribution of Health Status through ‘Upstream’ Strategies is Extraordinarily Difficult
Whatever the achievements of health promotion in targeting and altering individual behaviour, for example, anti-smoking campaigns, they have, in the main, failed to alter the distribution of health status among groups or classes. On the broader societal front, it is plausible to argue that it is too early to tell, and that health promotion activities have been inadequately funded to make a real difference. However, the evidence suggests that individually targeted health promotion and disease prevention tends to be more effective for higher socioeconomic groups than for lower socioeconomic groups (Lantz et al. 1998). Interventions that are supposed to benefit the disadvantaged benefit the advantaged even more, thus widening disparities.
Personal health practices and behaviours are very much influenced by the social and economic environments in which people live and work. Some face far more barriers to making ‘correct’ choices than others by virtue of the absence of positive reinforcement, peer values and expectations, and material circumstance. Modifying the distribution of health status is a major societal challenge requiring more than ‘upstream’ single-sector interventions. The data show that it is far easier to improve population health status differentially than to equalize it.
A Few Less Simple Challenges
So far we have identified features of the health and health-care landscape that suggest that diagnosing the barriers to health is easier than devising effective remedies. Similar and perhaps even more complex challenges confront public policy development.
O What a Tangled Web: The Determinants of Health
Just as the power of medical science exploded in mid-century, researchers began to explore the broader determinants of health in unprecedented depth. It was intuitively obvious prior to social scientific analysis that health and socioeconomic status were correlated. Now we have both data and increasingly persuasive expositions of the nature and extent of these connections (Graubard 1994). After decades of documenting the impact of lifestyle, researchers, most famously Marmot in the Whitehall studies, identified the underlying class-based gradient in health status irrespective of individual risk factors and habits (Marmot 1986). The confirming evidence grows continuously. Moreover, these relationships are inherently plausible: the upper classes tend to be visibly better off on all counts, and it would be peculiar if health status were somehow the exception.
Correlations may in themselves be highly compelling, but the gold standard for evidence is causation. Recently various evidentiary strands have been woven into a conceptual framework that describes how human biology interacts with both the physical and social environments and the health-care system to produce an array of health outcomes within a population (Evans et al. 1994). This analysis has drawn particular attention to the social factors—how individuals are brought up, the coping skills they develop, the degree of support from family and community, educational attainment, employment status, etc.—as crucial determinants of health (Sapolsky 1992; Suomi 1991). For example, we know that adequate nurturing and stimulation during the period from 0 to 6 years of age is critical to the healthy development of a child’s brain, and in particular, to building resiliency. The experience with Head Start programs in the United States clearly shows that early childhood interventions significantly improve prospects for a healthy and productive life among the children they serve (Bertrand 1998; Steinhauer 1998). These programs are designed to ensure that children develop the coping skills they require to thrive under very adverse conditions if such conditions cannot be changed.
Community characteristics also appear to influence the health and general welfare of individual citizens. Some communities cope effectively with, and ultimately overcome, adverse conditions—for example, massive unemployment, natural disasters, widespread crime and delinquency—while others barely survive or simply wither away (Hamel 1998). The most resilient communities exhibit good leadership, a sense of common purpose, and an intricate web of relationships among community members through the workplace, leisure, religion, and voluntary organizations (Kaplan et al. 1996). Whether healthy individuals invariably create healthy communities, or vice-versa, is an important question. Even if the influences are bi-directional, it remains essential to ascertain the level at which one would intervene to achieve the best outcomes.
There is also evidence of variations in the slope of both the health status gradient within societies, and of overall health status trends between countries. Japan and Eastern Europe have undergone major transformations linked with changes in overall population health status (Evans et al. 1994; Hertzman et al. 1996). Wilkinson’s work (1992) illustrates that overall life expectancy gains over the past 30 or so years have been greater in countries with relatively compressed income differentials. In short, societies have changed, both absolute and relative health indices have changed, and we have some, although incomplete, knowledge of how and why these changes occur. There seems little doubt that societies held genuinely accountable for both reducing health disparities and improving population health status would know roughly how to go about it.
Current realities are sobering. Disparities in market income are widening in most countries, although some have more effective buffers than others through government transfers (Centre for International Statistics 1998; Osberg 1998). Unemployment remains high in Canada and continental Europe. The United States, Japan, and the United Kingdom have been more successful. Some societies, notably the Scandinavian countries, have organized themselves to distribute the determinants of health more equally. Others have countervailing tendencies: the United States has low unemployment and huge inequalities, with the latter apparently responsible for its overall low health status ranking despite enormous health-care expenditure.
These barriers involve, to varying degrees, the classic tensions between ends and means. At times, society does not agree on goals: identifying disparities in health status does not mean there is consensus to eliminate them. Disputes about means are often fundamental: procedural barriers often confound implementation. There are also embedded political and institutional elements—both ends and means—that add to the complexity. If we view health and health care as political rather than rights-based or technical constructs, ‘doing the right thing’ for health may legitimately not be considered ‘doing the right thing’ politically.
The Temporal Challenge
People, and their governments, value current over future benefits, all else equal. The immediate and visible usually trumps that which is anticipated and opaque, particularly if posited as mutually exclusive alternatives. It is therefore extraordinarily difficult to withhold resources designed to produce a current benefit in favour of investments designed to produce future—and perhaps greater—benefit. Humans and our governments are, of course, capable of longer range thinking and do make farsighted decisions; we plan, we preserve national parks, education is by definition a future-orientated investment, but we are far less inclined to trade present for future health and health-care states than, say, current consumption for investment in majestic cathedrals that may not be completed in our lifetime. In light of this, public policy has to establish the appropriate discount rate for future benefits. That health researchers and epidemiologists might accurately project that certain changes and investments would produce better health status in the future does not mean that they ought to be masters of public policy. People may value modest current utilities over far greater future utilities. Psychological rationality may conflict with a more strictly utilitarian long-range accounting. Even when adverse future consequences are quite certain—for example, among smokers—risk-taking behaviour often persists. In a democracy, public policy must win the approval of the same people whose preferences and behaviours may not highly value planning and foresight, and even, in some sense, self-interest.
The Epistemological Dilemma
The evidence for health-orientated social policy is epistemologically less solid than the evidence arising from controlled clinical trials at the heart—in theory—of contemporary medicine. Moreover, the evidence in the social policy sphere is almost always correlational; causality is theoretically inferred, not experimentally demonstrated. Social policy reasoning and ‘proofs’ do not work like algebra (based on abstract and formal logic) or pharmacotherapy (often based on observable physical phenomena). The mechanisms of action are invariably approximate and often qualitative. This is not normally a problem in the public policy realm, where positivistic social engineering visions have fallen into disrepute, and democracies tend not to hold governments accountable for finely calibrated effects. We seem to have absorbed, however impermanently, the ancient lesson that politics is discussion and persuasion, not calculus.
Yet, the epistemological bar is set higher for health policy. Health care, especially in the latter part of this century, is highly technical and places a premium on controlled experiments. Among insiders and experts, understanding the mechanism of action of interventions is highly valued; the unit of analysis has refined to the molecular level. Much of medicine aspires to the status of a natural science. Its methodological adherents (who are also competitors for public and private resources) often challenge health policy advocates to justify their cases with similarly rigorous and transparent ‘proofs.’ There is a tendency to expect all policies related to health to adhere to the same concepts of rigour and causation (Mustard 1996). The citizenry demands far greater accountability of health policy because it perceives that diminished levels and quality of health care result from attempts to alter health ‘determinants.’
Knowledge and Gridlock
A simple and straightforward understanding of health can be empowering; conversely, knowledge of the complex determinants of health can lead to policy paralysis. If wealth, status, power, and their distribution largely determine the distribution of health, can any health policies, in the end, create effects independent of general economic and political policies? Those who think that astute health policy, rather than more fundamental material and social transformations, can improve absolute or relative population health status may be unduly optimistic. In a sense, the evidence about the determinants of health plays into the hands of those who believe that health policy tinkering is destined to be overwhelmed by broader forces.
The Redistribution Dilemma
Health policy has the potential to alter the distribution of two types of benefits among the population. Providers of health care owe their livelihood and status to the health-care system, and its characteristics at a given time. Rearranging health care rearranges resources and incomes; in a finite world, this creates winners and losers, and one can expect prospective losers to oppose change that may be laudable on wider grounds. If health policy diminishes the emphasis on health care in favour of more social interventions and programs, the health-care constituency—a substantial force in all developed countries—will consider itself under siege and will predictably create or highlight alarmist scenarios designed to create support and nostalgia for the status quo ante.
In addition, health status benefits may be redistributed if health policy is successful. If the goal is to reduce health status inequalities, there are four logical options:
- increase the health status of the worse off more than the health status of the better off;
- increase the health status of the worse off but hold constant that of the better off;
- hold constant the health status of the worse off, and lower the health status of the better off;
- lower the health status of the worse off less than the health status of the better off.
We can dismiss options 3 and 4 as too disheartening to articulate as public policy objectives. Of the two more obviously attractive options, 1 is less disconcerting because it promises something positive for all. In either case, that part of the population with a strong sense of entitlement to be winners in most spheres of life will see its health expectations uncharacteristically subordinated to that of others. The issue is further complicated by the fact that different segments of the population tend to need different kinds of interventions to improve health status. The well off tend to benefit from expensive technological innovations in health care because their nonmedical determinants are typically sound (they are well educated, employed, housed, fed). Those at the bottom end of the spectrum need health care to be sure, but their ticket to durably improved health status is improvement in both their absolute and relative material circumstance. Reducing disparities means precisely that those at the top end will do less well than they would were we indifferent to the magnitude of disparities—regardless of whether their absolute levels of health status continue to improve.
The Power of Belief Systems
People’s beliefs about what is important and what is not, and what works and what does not, may influence health policy far more profoundly than research-based reasoning. Belief systems are complex and multifaceted phenomena. They are deep-rooted and inherently stable; they define individuals and populations in the same way that constitutions and jurisprudence define functioning democracies. Yet, although they are fundamental, they need not be rigid; human action and leadership can change them. Policy and belief systems can be mutually reinforcing, but dramatic policy initiatives, to be politically viable, must be compatible with dominant belief systems. Beliefs about health, spirituality, entitlement, hierarchy, fairness, and government set implicit constraints on the nature and scope of policy. Major economic and political policy changes ought therefore to flow from altered understandings and preferences, or at the very least a strong dissatisfaction with existing arrangements.
This suggests that change is likely to be evolutionary, particularly in reconceiving concepts of health, fairness, and collective public action. Belief systems are not easily shaken by data. There is a large and growing use of so-called alternate therapies among educated people (Canadian Medical Association 1997). People are fascinated by, and well disposed towards, sophisticated medical interventions and their impact, but much less so with ‘social engineering.’ We respond more viscerally to small numbers of dramatically and seriously sick people (those with AIDS, cancer, ALS) than to large numbers of people who are ‘merely’ unhealthy much of the time (the chronically ill, the undernourished). Societies might have a sophisticated understanding of what creates and diminishes health, but far more volunteer (and government) money goes to medical rather than social services. When declarations in favour of health for all confront the inegalitarian realities of rich societies (let alone desperately poor ones), the cognitive dissonance becomes almost overwhelming.
Redefining much of public policy in health terms is in a sense revolutionary. Given the obstacles to effective, widely supported, and lasting health-orientated policy development, there is a great deal of public intellectual groundwork to lay. It is not enough to persuade a majority of people that economic and social policy should serve health-enhancing ends; one must anticipate and intellectually disarm the critics. The Clinton health reform debacle is here instructive: while a majority of Americans consistently decry the follies of their health-care system, their ostensible desire for change is hostage to a more fundamental antipathy to government-run systems and to the lavishly funded scenarios promulgated by private insurers.
Finally, much current health policy thinking revolves around the assumption that adopting a population health perspective is inherently desirable: to understand it is to hold it. However, there is no reason to believe that the public would prefer a population health perspective, and the policy consequences that flow from it, if they perceive it to endanger the quality or accessibility of health-care services. Perhaps more important, there may be far less support for the goal of maximizing population health if the means are unacceptable. There may be consensus to mitigate, but not eliminate, the disparities inherent in a thriving capitalist economy. There may be implied or explicit limits to the public’s desire to maximize population health, particularly if it wishes to maximize other things such as aggregate wealth. If we accept the proposition that most people are utility maximizers most of the time—without denying the capacity for genuine altruism and communitarian sentiments-then both individual and population health will count as only two of many competing utilities.
Agendas in Pursuit of a Vital Health Policy
All analyses of potential ‘solutions’ to health policy dilemmas derive from implicit or explicit objectives. The primary assumption of our position is that improving health is a desirable and broadly supported goal. Its organizational corollary is that public policy is instrumental to its achievement, and government has a number of legitimate roles to play, examples being direct interventions, redistribution of resources, regulation, and creation of incentives. Other explicit assumptions and objectives are listed below.
- Establishing health goals should be a fundamental cornerstone of public policy.
- Reducing health status inequalities is inherently desirable.
- Government properly frames social policy objectives and uses its powers and moral authority to advance them.
Any initiatives should respect and, if possible, advance democratic processes and participation. That is, good public policy requires public consent. This is not to suggest that public policy cannot provide leadership and mobilize public support that may not be apparent initially, or that policy-making should be more responsive than initiating, but ultimately, public policy is for the public and good public policy must be supported by the citizenry at large.
Effective and sustainable health policy will, then, involve a good deal of civic groundwork—building an audience for the concepts, creating broad-based support for goals, creating awareness of the linkages between health and other societal constructs, and stimulating inter-sectoral partnerships. Needless to say, the following strategies are generic, and their success in particular circumstances will depend on a wide variety of factors, including political culture, economic conditions, social capital, leadership, and chance.
The Health Information Agenda
Health information systems have been developed principally to administer health-care systems. As such they are in the main misnamed; they have not been about health, but about sickness and the units of service deployed to address it. These data systems are enormous achievements and sustain important health services utilization and clinical research, but their ore is less rich for the purpose of informing health policy from a broad population or determinants of health perspective.
The problem may be illustrated by two approaches to the health record. The conventional approach would be to apply ever more powerful computing technology to health care, creating a real-time virtual medical record that begins by consolidating existing health data. This ‘virtual medical record’ would contain basic demographic data (age, sex, residence), and a great deal of utilization data. Plans for expansion would include demographic variables (occupation, family structure), refined utilization data (patient- and doctor-specific diagnostic testing data), and outcomes data associated with major procedures. The expanded record would remain anchored in contacts with the health-care system.
A genuine health record would look much different if the goal were to assemble the data elements essential to understanding individuals’ health status over the course of a life (Wolfson 1994). It would include variables such as household income in the formative years, genetic characteristics and risk factors, psychological profile; work history, characteristics of communities lived in (size, industrial profile, income distribution, environmental factors, etc.), seminal behaviour patterns, and a whole host of items that are known to influence health status. The virtual medical record would be supplanted by a virtual record of health determinants. Certainly one would include the medical record in the personalized profile, but its elements would in essence be dependent rather than independent variables.
There are huge challenges to creating such a database for population health and policy impact studies. Creating a comprehensive, person-specific profile raises profound privacy issues. The spectre of intrusive social engineering, risk-rating, and other unpalatable alternatives is invariably present despite legislative and ethical protections. Nevertheless, if policy is to be informed by good information, and evaluated persuasively, these reconceived databases are prerequisites. A good deal can be done by creatively linking existing data sets (administrative health care data, census files, income data, health survey data), but it may well be that the whole enterprise needs a fresh conceptual examination to overcome constraints imposed by traditional approaches.
These innovations will require years to develop and yield higher-order descriptive and explanatory information. There are short-term options that may produce valuable and compelling insights with the power to shape health policy. Case studies and qualitative investigations trade off breadth for depth, generalizability for understanding. These methods are not new to some disciplines, but they have become valued in health policy and behavioural research quite recently. Health policy has often been made in response to vivid stories and anecdotes; presumably it might also respond to new stories extracted from systematic, in-depth investigations. The definitive explorations and evaluations will have to wait for the reconstruction of health information systems, but meanwhile we are developing a variety of tools to obtain policy-relevant understandings of both need and the impact of various structures and interventions (Fisher et al. 1998; Tranmer et al. 1998).
Building Public Support for Policy Renewal
Once we have assembled existing research and built powerful new information systems, we must deploy them to good effect. The distribution of health is substantially political, and the adage that knowledge is power is at least partly true. The compelling tales to be told about the accumulating evidence on health, wealth, and social characteristics are all too often confined to the seminar room and the learned journals. While far from being arcane and turgid laboratory accounts, social data and trends have a tough time competing for the attention of a generation weaned on satellites, gigabytes, and cloned sheep. We retain some optimism that civic engagement and the appetite for reflection will grow, but even in the face of significant public indifference to reading and discussion and a sense of political alienation, there are options.
A partial solution is good packaging and careful marketing to important audiences. The public has shown a greater appetite for acutely presented social analysis than researchers often assume. Fictionalized accounts of important social phenomena have often attracted large audiences; Upton Sinclair’s The Jungle, and Steinbeck’s The Grapes of Wrath are two famous examples. In Canada, a demographic and economic analysis of historical trends and their implications for the future—David Foot’s Boom, Bust and Echo—topped nonfiction bestseller lists for two years. It is quite possible to translate scholarly works into essays and articles for the popular press, but there has to be a will and a strategy to reach the larger audiences in various venues.
A crucial message is that health is largely a function of how society organizes itself and the values that underlie it. This is obvious to population health researchers and is not entirely foreign to the thinking of the public (Ekos 1998; National Forum on Health 1997a), but the nature and strength of the linkages need reinforcing and social marketing in the best sense. The health impact of public policy options is, even if properly considered, rarely articulated. Both fiscal and monetary policy influence unemployment rates and income distribution, but as yet health impact analyses are not part of the public policy discourse in the same way that environmental impact assessments are (Lin et al. 1997). Driving home the message may require a central, highly visible focal point. In Canada, the National Forum on Health recommended establishing a Population Health Institute that would have a public education and media penetration agenda, and which, using the best available evidence, would propose policy options for addressing critical health issues (National Forum on Health 1997a, 1997b).
A vital piece of information that should cause some reflection at all levels of society is the connection between income distribution and health status. We have noted that there may be powerful societal divisions on the desirability of reducing material inequalities, but there may be a much stronger consensus in favour of reducing inequalities in health status because it is an argument that can appeal to both ends of the political spectrum (though for different reasons). The left considers increased equality to be an intrinsic good. Few disagree that health is a precondition for full participation in the economy. Not to caricature conservatives, but let us here assume that they have fewer moral objections to serious inequalities. It would be useful to provide an accounting of the costs of these inequalities in terms of lost productivity, idleness, reduced demand for goods and services, crime and a vast system to protect against it, etc. Appealing to old-fashioned self-interest may be just as effective as appealing to nobler sentiments. Educating the public and politicians on both the disparities in health status and their consequences for economic participation may not in itself create a tidal wave of support for reorganizing the economy, but it should give greater impetus to the view that the level of inequality may be well beyond that which is defensible on either self-interested economic or compassionate grounds.
Reaching the Corporate World
There are three main audiences for the population health policy message. Two are obvious: politicians and the general public. The third may be the key to building support for major changes in health policy. This audience is the workplace, and particularly corporations.
There is a great deal of interest in the health of the workplace and work force. Economic self-interest is here a powerful unifying force. Healthy workers (in both a physical and psychological sense) are more productive, less likely to be injured, less likely to be absent, and reduce current and future liabilities for worker-related health care and rehabilitation. Large employers have long recognized the importance and potential payoffs of programs to improve the health of the work force. Traditional workplace safety standards have given way to more sophisticated and multifaceted programs to improve health. Many employers and unions negotiate health-orientated benefits plans that extend beyond reimbursement for non-publicly-insured health care.
The workplace has an enormous impact on health, and some of the effects may be time-lagged, manifesting fully long after the worker has retired (Avison 1998; Karasek and Theorell 1990; Polanyi et al. 1998a, 1998b; Sullivan et al. 1998). In a sense, the workplace is a population health laboratory where many of the determinants of health come into play. While Ordinary people’ may be indifferent to the effects of current practices and behaviours on future health status because of our psychological make-up, corporations are disciplined by competitive pressures and motivated by the advantages to be gained from treating workers as capital investments rather than expendables. As a result, they should be avid consumers of information that suggest which workplace health policies are likely to pay off over the long term.
Furthermore, as more corporations get the determinants of the health message they will come to realize that progressive policies are just as essential outside their immediate environments. There will be no healthy workers if there are no healthy children. It is to the advantage of corporations to operate in an environment in which they do not have to preoccupy themselves with setting up parallel systems to promote health. Greater awareness of the determinants of health could very well lead to a recognition that a more socially sensitive policy agenda ultimately serves individual and corporate interests better than its absence.
Taking Accountability Seriously
Governments live and die by certain accountability measures: the growth in the GDP, the unemployment rate, fiscal indicators. There is considerable—perhaps excessive—accountability for health care, but not for health. Consequently, policies are almost exclusively orientated towards health care. The means are mistaken for the ends, and most of the ‘means’ responsible for health status are not included in the accountability framework.
Governments may be disinclined to commit themselves to health goals for several reasons. There may be no consensus on what those goals should be. They may perceive their own powerlessness to change health status. They may be forced to spend money on health care that they know will not improve health status even while it generates political capital. Regardless, the absence of quite precise and widely articulated health goals defines accountability in process terms, which in turn emphasizes health care at the expense of interventions in the determinants of health.
It is therefore important that governments establish health goals, preferably for each important societal sector or subgroup. These goals will not only be targets to reach; they will focus attention on evaluation and effectiveness measures, and will provide a defence against claims for more health-care resources in areas where the returns will be minimal. The difficulty lies in the secular trends: health status seems to be getting better (at least life expectancy is increasing quite dramatically), and no one knows exactly why. If the trend continues, government may be tempted to claim credit for improvements despite an inability to connect the outcomes with anything the government did. This interesting possibility aside, goal-setting requires deliberation, and adds a dimension to public discourse that shifts attention from anecdote and process. Setting goals is therefore part of the civic educational effort that in our view builds the foundation for health policy reconfiguration (Kushner and Rachlis 1998). If the goals are meaningful and public, based on values and best available evidence, the means revert to the status of means rather than ends.
Saving on Health Care, Investing in Health
Understanding the etiology of, and variations in, health status tends to focus more attention beyond the health-care sector. It remains important to scrutinize the health-care sector for many reasons, not least of which are the enormous resources it consumes. The expansionist tendencies of health care have been noted above. The growth of health services, evaluation, and utilization research has revealed a considerable degree of ineffectiveness and inefficiency. If we are able to jettison those aspects of health care that are obsolete, unnecessary, or harmful, the realized savings could be deployed in the service of creative health-oriented policies and programs.
There is an unusual skew in conventional discourse about the funding of health-care systems. Despite the startling lack of a detectable relationship between health-care expenditure and health status in industrialized nations (GRIS 1998), the possibility that health-care systems are seriously overfunded is rarely raised. There are a number of possible reasons for this silence. As noted above, there is neither general nor system-specific accountability for health status. Population health status and outcomes may be too stringent a measure of the value of health care; the public appears to value accessibility in itself, as well as attempts to defeat illness even if unsuccessful. Health-care providers almost invariably claim that more money would allow them to perform better. Societies may equate their own status and maturity with the presence of a large medical infrastructure and expensive technology, and it is difficult for either individuals or governments (although far easier for the latter) to be prudent purchasers of health care given the asymmetry of knowledge and the understandable tendency to hope for possibilities rather than resign oneself to probabilities.
It remains important to intensify scrutiny of how health-care dollars are spent and subject health care to a stricter accountability. The more health-care is considered both an essential service and a commodity to be consumed in ever-greater quantities by wealthy societies, the harder it is to constrain. Undermining public faith (as opposed to rational and defensible confidence) in the health-care system is in a sense instrumental in creating support for a wider agenda. This could have two principal effects: opportunities to redeploy resources may emerge, and the public will be somewhat less devoted to the notion that health care is the solution to health problems. If skepticism is a prerequisite for transformation, there needs to be greater awareness among the public that the healthcare system does not explain very much of the variance in health status.
Communicating the Civic Dimensions of Health
Reconfiguring health policy is difficult but achievable. Success requires first the abandonment of comforting assumptions. We should not assume societal consensus that we should invariably act on the determinants of health to improve population health status. If pressed, there will be credible groups that challenge the wisdom of adopting a population health perspective. Achievements the public may reflexively regard as desirable (such as reduced health inequalities) may on further analysis be rejected as too expensive or disruptive of valued social norms. An inability to explain precisely how certain policies will achieve specific goals may cause prospective allies to shift their priorities elsewhere.
The second requirement is sound strategic thinking about health policy in the context of democratic politics. In the end, the public has to support health policy, which means it will have to be persuaded that the ends are just, and the means are essential or at the very least tolerable. Political leadership must be similarly convinced in both absolute (the policies are worthy in themselves) and relative (they are worth pursuing more than the alternatives) terms.
Many broad policy or programmatic interventions have been successful, but the public is not always aware of them. The competition for public allegiance is staged in the media. Health policies are means to an elusive end, products in search of a market. A strategic approach to highlighting the interactions among health determinants and health status, as well as changes attributable to effective policy, would seem essential to generating a widespread public mandate to effect change.
A third element is to focus on smaller, defined, specific initiatives that have made a difference. It is crucial to avoid the impact fallacy: just because everything is ultimately connected to everything else does not mean that smaller actions are futile. Small policy and resource allocation changes can make a big difference for some people. Communicating the results may create a groundswell for larger scale transformations. The microlending phenomenon in developing nations is an example of a seemingly tiny program that may end up fundamentally changing the economies and social hierarchies of millions of people (Robinson 1996). Among the most satisfying aspects of Canada’s National Forum on Health was its effort to seek out and communicate concrete success stories about improving health in specific populations (Anisef 1998; Bagley and Thurston 1998; Bennett and Offord 1998, Breen 1998; Caputo and Kelly 1998; Chappell 1998; Dyck et al. 1998; Fralick 1998; Godin and Michaud 1998; Gottlieb 1998a, 1998b; Lord and Hutchison 1998; Marshall and Clarke 1998; McDaniel 1998; Morrongiello 1998; Nahmiash 1998; O-Brien-Cousins 1998; K.A. Scott 1998; Singer and Martin 1998; Sudermann and Jaffe 1998; Tamblyn and Perreault 1998; Wolfe 1998; Zayed and Lefebvre 1998).
Perhaps the most fundamental strategic issue is whether we should regard health policy as logically prior to, or as a product of, broader social and economic policies. Should we address health status inequalities directly, concentrating on health-enhancing programs rather than general economic and social restructuring, or should we focus on the latter on the assumption that better health will follow inevitably? In other words, do we need to concern ourselves with health inequalities in particular if we solve the problem of socioeconomic inequalities in general?
Doubtless the interaction is bi-directional. Good health is a prerequisite to most forms of social and economic participation, while persistent socioeconomic inequalities render the attainment of good health improbable for disadvantaged groups. In light of this, the choices are strategic rather than binary; there is no either/or scenario guaranteed to produce the best results. Nevertheless, if we assume a finite capacity to introduce policy initiatives and mobilize ‘civic capital’ to effect change, it would appear wise for those who view the world through health lenses to engage in the broader political and economic discussions. There is nothing inherently virtuous about trying to improve health status in isolation from economic and political advancement. Indeed, the synergistic effect of progress on several fronts is almost certain to be more powerful than more narrowly focused policy initiatives.
Reconfiguring health policy, then, requires thoughtful responses to emerging paradoxes. Healthy people can and do get ahead; but if they get too far ahead, others will be unhealthy because relative rather than absolute circumstances predispose towards good or ill-health after genetic and other luck-of-the-draw factors are controlled for. The loss of faith in ‘big government’ may have salutary effects on the economy and self-reliance, but if political cynicism translates into detachment from civic activities and community-building, health disparities will persist and new problems may emerge. A sense of remoteness and inability to influence huge organizations—be they governmental or corporate—can create a sense of either alienation or malaise. We do not fully understand the mechanisms by which a sense of powerlessness or disengagement, despite relatively good material conditions, translates into health status outcomes, but the Whitehall data have suggested that the combination of high stress and low control over one’s environment are associated with poorer health status, while high stress and high control are not (Syme 1991).
If these relationships are confirmed by further research, the health policy vocabulary will have to include terms such as civicness, power, citizenship, and industrial strategy. Putnam (1993) attributes the comparative vitality of northern Italian regions compared with their southern counterparts to centuries-old differences in civic traditions. Community development theorists argue that the act of acquiring power over one’s destiny has more lasting impact than the specific ways in which the power is applied. In Canada, some regional health authorities have established community development teams to address the needs of marginal groups by building their capacity to participate, in addition to ensuring access to services. Conceived in this way, reconfiguring health policy is substantially about extending and enriching democratic participation. While many decry the introduction of politics into matters of health, the web of accumulating evidence suggests that there is no alternative.