What makes some people healthy and others not?
It is a simple question with complex answers.
Doctors usually look at the individual. They look at symptoms like pain, swelling, discharges, the chemical composites and viral or bacterial invasions of blood and other fluids. They look at x-rays and other imaging. They open bodies up and look inside physically.
Then they make a diagnosis, prognosis and a treatment regime. The treatment leads to cure or the stabilising of the condition or it fails and leads to death.
That is one way of looking at health.
The other is to look a public health. To look at the state of whole populations or groups within populations. This comes under the heading of epidemiology. It helps in producing prevention, rather than cure.
The big public health programs in the industrialised world took place from the middle of the 19th century to the middle of the 20th century. Clean water, sewerage, immunisation and so on.
The first way is individualistic. It deals with health care and has dominated recent debate in Australia. How do we fund the health care of individuals? How much should be government and how much private? The individualistic approach dominates debate because it is immediate. It is about cures and paying for cures, subjects that grab immediate attention of media and politicians.
Far less sexy is public health. People just do not know prevention is happening, of its nature.
This week, the National Centre for Epidemiology and Population Health invited Dr Fraser Mustard to town. Dr Mustard is from Canada, where he has done a lot of work on this question of what makes some people healthy and others not.
He is interested in the economics of health, but does not push the view that ever greater amounts of money must be put into health care. Almost to the contrary. He is worried that in economies where primary wealth generation is flagging, the capacity to put money into secondary wealth generation (health, opera singers and the like) falls too.
But Dr Mustard also looks at the economics-health relationship from the opposite direction. He argues that if a population is unhealthy it cannot generate primary wealth as effectively.
In short, we (especially economists) have to widen our view. We cannot look at economic growth as purely the product of capital, labour, land, natural resources and innovation and the like. No; the capacity of a nation to deliver economic growth and adjust to technological change will depend on the health of its population as well.
Dr Mustard takes us through two more steps.
The health of the population does not depend only on how much money is thrown at health care, health technology and the like. Nor purely on the matter of public health largely solved in the 100 years to 1960, like clean water, sewerage and immunisation, or even the more recent public-health matter like exercise and diet. It depends also on the way people fit in society, the amount of control they have in their work and the level of equality in society.
Recent English studies among civil servants with access to equally good health care revealed those with less control in their working lives have a higher incidence of heart disease.
The second step in the argument is that the way people fit and the level of control depends very greatly on their development in early childhood in the years up to five or six. Children who get more sensory stimulation during the early development of the cortex will develop better brain power (cognitive and behavioural characteristics) that will help them cope better in adult life.
As a journalist watching politicians deal with health and other issues this is alarming stuff indeed.
Dr Mustard’s thesis (and he would acknowledge that much of it is built on the work of others) calls for action in the very areas that politicians since the Thatcher-Reagan revolution (and perhaps before) have shown no interest in.
They do not care about taking action or spending money on things which produce no immediate, tangible result. “”We prevented many deaths and much suffering,” cuts no ice. Research into long-term trends and disease incidence will not bring short-term breakthroughs so is lower on political funding priorities. We want winners, and winners now.
They are not interested in equality, believing that rugged individualism will lead to a better life for all through the trickle-down effect. In fact, inequality in itself is causing poor health which in turn will affect long-term economic performance. But it will not be easily measurable. We might attain good growth figures but it is difficult to prove they could be better and the quality of life on average would be higher without the stress and anger at the bottom and insecurity at the top.
Thirdly, they are not interested in children under the age of six. These children are not measured. The state does not require them to be educated, stimulated or nurtured. It requires only that their parents do not seriously neglect them physically. This, despite all the rabbiting on about the family by politicians. And as the baby-boomers children grow up the whole emphasis in health is becoming more geared to fixing the consequences of individuals’ ageing, rather than on the total health of the population.
Dr Mustard is less pessimistic. In Canada he persuaded politicians in his Province of Ontario to set up the Canadian Institute of Advanced Research which takes a lot of thinking out of boxes. Health, economics, artificial intelligence and robotics and researched together.
It is not a capitalism vs socialism matter. Indeed, Dr Mustard has argued that getting public spending under control is necessary to achieve good health outcomes, provided cuts are made in the right areas and the remaining spending is done wisely. Dr Mustard was not beyond a little competitive federalism in presenting his argument about the need to work on general health outcomes, arguing that Ontario’s performances were worse than other Provinces.
Clearly, on Dr Mustard’s argument, the command economy of socialism is never going to produce good health outcomes simply because people do not have enough control over their work or lives to be relieved of illness-inducing stress. Perhaps that explains the difference in health outcomes between the old East and West Germanies when the people in the East had access to universal health care.
Rather it is a difference between what sort of capitalism you are going to have: a purely selfish one or one that looks at social capital as well as economic capital as a means to giving the population the wherewithal to lead fulfilling lives.
On present thinking we are concentrating too much on treating symptoms at an individual level at vast expense while broader causes (like early childhood stimulus and workplace powerlessness) go unattended – or worse are not even associated with health or economic productivity.