“Pursuing the wrong - Cambridge Institute of Public …...“Pursuing the wrong problem: the...

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CAMBRIDGEThe Primary Care Unit

“Pursuing the wrong problem: the history of public health policy to

reduce health inequalities in the United Kingdom”

Professor Mike Kelly

Primary Care Unit, Institute of Public Health,

University of Cambridge

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Life expectancy males: England.

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Life expectancy: males East of England.

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Life expectancy females: East of England.

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Repeated Policy attempts to change things.

• Prevention and Health – Everybody’s Business (1976).

• The Health of the Nation: A Strategy for Health in England (1992).

• Saving Lives: Our Healthier Nation (1999).

• Tackling Health Inequalities: A Programme for Action(2003).

• Choosing Health: Making Healthy Choices Easier (2004).

• Healthy Lives, Healthy People (2010)

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These policies have a number of characteristics.

• Focus on risks to health from tobacco, alcohol, obesity, lack of exercise.

• Talk about the importance of getting the right messages out to the population.

• Much emphasis on behaviour change.

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The long shadow of cholera.

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The shorthand history of nineteenth century public

health.

• John Snow.

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health.

• John Snow.

• Sir Joseph Bazalgette.

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health.

• John Snow.

• Sir Joseph Bazalgette.

• Koch, Lister, Pasteur.

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• The nineteenth century was one of public health progress in which germ theory eventually triumphed and in which public health measures eradicated deadly infections like cholera.

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The pathogenic paradigm.

• If a cause can be identified acting on that cause provides a solution.

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The pathogenic paradigm.

• If a cause can be identified acting on that cause provides a solution.

• Cholera is the paradigmatic example.

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The twentieth century.

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Doll & Hill and tobacco.

• The identification of specific pathogens and dose response relationships.

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• But smoking is a behaviour.

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• But smoking is a behaviour.

• Paradigm shift?

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Risk, cause, prevention.

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The discourse of risky behaviours

• Tobacco

• Alcohol

• Inactivity

• Food

• Drugs

• Travel

• Sex

• Age

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The discourse of risky behaviours

• Tobacco

• Alcohol

• Inactivity

• Food

• Drugs

• Travel

• Sex

• Age

• Being alive

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The non-shorthand version of nineteenth century public

health.

• Leith and cholera.

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• Venters, G.A. (2015) Leith in the time of cholera - the story of Thomas Latta, HektoenInternational, Winter 2015.

• http://www.hekint.org/index.php?option=com_content&view=article&id=1318

http://www.hekint.org/index.php?option=com_content&view=article&id=1318

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The non-shorthand version of nineteenth century public

health.

• Leith and cholera.

• The Broad Street Pump

• The Thames Embankment.

• Edwin Chadwick.

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• Kahneman, D. (2011) Thinking, Fast and Slow, New York: Farrar, Strauss & Giroux.

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• Is Donald Trump a good President?

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• What is 56,674,237 divided by 13?

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Thinking fast about causes.

• Cause and effect.

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• Simple linearity.

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• Policies on non-communicable disease in England.

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Repeated Policy attempts to change things.

• Prevention and Health – Everybody’s Business (1976).

• The Health of the Nation: A Strategy for Health in England (1992).

• Saving Lives: Our Healthier Nation (1999).

• Tackling Health Inequalities: A Programme for Action(2003).

• Choosing Health: Making Healthy Choices Easier (2004).

• Healthy Lives, Healthy People (2010)

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• Policies on non-communicable disease in England.

• “Its about behaviour change stupid; and that’s easy”.

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The dominance of the proximal risk factor

approach to aetiology.

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• Focus on behaviour change.

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• Focus on some of the wider determinants -but not historical or biological ones!

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• Focus on some of the wider determinants -but not historical or biological ones!

• Little attention to the mechanisms of prevention.

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Implications of the non-complex version.

• Individualistic.

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• Reductionist.

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• Reductionist.

• Behaviour abstracted form social context.

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• Reductionist.


• Vested interests ignored

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• Reductionist.


• Vested interests ignored

• Lip service paid to Wider Determinants.

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Rethinking the question.

• Health inequalities have a recurrent historical dimension – what do the historical data and evidence tell us about the patterning of health inequalities?

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• Health inequalities are biological as well as a statistical phenomena, so where is the biology in current policy?

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• Health inequalities are a biological as well as a statistical phenomena, so where is the biology in current policy?

• Health inequalities represent fundamental economic differences in the population, so where is the Economics?

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Rethinking means “thinking slow”.

• We need to integrate historical, social, psychological, economic and biological phenomena.

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Rethinking means “thinking slow”.

• We need to integrate historical, social, psychological, economic and biological phenomena.

• And we must distinguish between aetiology and preventive interventions.

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Thinking slow.

• Also involves acknowledging that the mechanisms causing the patterning of population health are not the same as those explaining individual health outcomes.

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• In fact these ideas have been around in the psychological and sociological literatures since at least the 1940s.

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• There are social and psychological factors involved in disease aetiology.

• There are different social and psychological factors involved in why interventions are effective.

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Mechanisms of prevention/

implementation.

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implementation.

• Delivery.

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implementation.

• Delivery.

• Delivery sub-optimally.

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implementation.

• Delivery.

• Delivery sub-optimally.

• Delivery, accessibility, use by different sections of the population.

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• Costs and opportunity costs of delivery done sub-optimally.

• Costs and opportunity costs of doing things optimally?

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A relational and dynamic approach.

• Individuals and populations interact differentially to interventions and these interventions are also implemented differentially.

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• The WWWWW test.

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A relational and dynamic approach.

• Individuals and populations interact differentially to interventions and these interventions are also implemented differentially.

• Will it work on a wet Wednesday in Wigan?

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Conclusion.

• The ways in which interventions work in different segments of the population not well understood and should be an urgent priority.

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Conclusion.


• Still a much greater focus on cause than on prevention in policy and the assumption that if you know the former you will be able to do the latter.

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Conclusion.


• Still a much greater focus on cause than on prevention in policy and the assumption that if you know the former you will be able to do the latter.

• But cause is the necessary but not sufficient condition - it tells you what to do but not how to do it!

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References

KELLY, M.P. & BARKER, M. (2016) Why is changing health related behaviour so difficult? Public Health, 136: 109-116 http://dx.doi.org/10.1016/j.puhe.2016.03.030

KELLY, M.P. & RUSSO, F. (2018) Causal narratives in public health: the difference between mechanisms of aetiology and mechanisms of prevention in non-communicable diseases, Sociology of Health Illness. . 40 (1): 82–99. http://onlinelibrary.wiley.com/doi/10.1111/1467-9566.12621/pdf

SZRETER, S., KINMONTH, A.L., KRIZNIK, N.M., KELLY, M.P. (2016) Health and welfare as a burden on the state? The dangers of forgetting history, The Lancet, 388: 2734-35. http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)32429-1.pdf

KRIZNIK, N.M., KINMONTH, A.L., LING, T., KELLY, M.P. (2018) Moving beyond individual choice in policies to reduce health inequalities: the integration of dynamic with individual explanations, Journal of Public Health. https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdy045/4931230?guestAccessKey=af9f5249-b3b7-4270-92db-421e9c8fb5ac

KELLY, M.P., KRIZNIK, N.M.., KINMONTH, AL., FLETCHER, P.C. (2018) The brain, self and society: a social-neuroscience model of predictive processing. Social Neuroscience https://www.tandfonline.com/doi/full/10.1080/17470919.2018.1471003

http://dx.doi.org/10.1016/j.puhe.2016.03.030

http://onlinelibrary.wiley.com/doi/10.1111/1467-9566.12621/pdf

http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)32429-1.pdf

https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdy045/4931230?guestAccessKey=af9f5249-b3b7-4270-92db-421e9c8fb5ac

https://www.tandfonline.com/doi/full/10.1080/17470919.2018.1471003

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• Thanks to the St John’s College Reading Group on Health Inequalities in Cambridge. https://www.joh.cam.ac.uk/st-johns-reading-group-health-inequalities and the Annual Fund of St John’s College, Cambridge, the Wellcome Trust [097899] and the Arts and Humanities Research Council (AHRC) (UK), grant number AH/M005917/1 (“Evaluating Evidence in Medicine”).

https://www.joh.cam.ac.uk/st-johns-reading-group-health-inequalities

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