Sick Societies – Responding to the global challenge of chronic disease
Chronic disease isn't just an issue for the developed world. It causes an 80% greater burden of death and disability than infectious diseases in low and middle income countries. This dramatic increase is the result of putting wealth before health.
That's the verdict of Sick Societies, which looks at the growth of chronic disease, in particular in the developing world - including case studies from Brazil, China, India, Mexico and South Africa. Sick Societies, edited by public health scholars David Stuckler and Karen Siegel, considers:
The causes and consequences of chronic disease on a global level. Heart disease, common cancers, respiratory disease and diabetes are described as the four main killers, responsible for more than 35 million deaths a year worldwide. Tobacco use, unhealthy diet, physical inactivity and alcohol are seen as the main behavioural risk factors.
According to a 2005 estimate in The Lancet at least 80% of heart disease, stroke and type 2 diabetes and 40% of cancer could be avoided through healthy diet, regular physical activity and avoiding tobacco.
How people’s decisions about whether to use tobacco, drink dangerously, or eat unhealthy diets are strongly influenced by their price, availability and marketing. The editors trace this back to the vested interests of multinational corporations, whose access to markets in the developing world has been assisted by ‘neoliberal’ economics and ‘free market’ deregulation, privatization and liberalisation. Marketing takes advantage of the fact that biologically, people have strong preferences for food high in fat, sugar and salt, which also happen to be some of the most profitable ingredients; and also of poor people living from pay day to pay day, who are more likely to focus on the present and on immediate pleasure than on long term chronic disease implications.
The editors argue, ‘we create societies where tobacco, alcohol and foods containing high levels of salt, sugar and fats are the easiest, cheapest and most desirable choices, while fruit, vegetables and exercise are the most expensive, inaccessible and inconvenient options.’
The consequences of chronic disease, for those affected, their families, communities and societies – including economic as well as health implications. Where there are no social support systems or health insurance, these consequences can be intergenerational. The cost of medicine and care may lead children to leave school early and force women back into traditional care giving roles – trapping families in poverty for generations.
The limitations of healthcare systems set up to deal with infectious diseases and provide acute medically oriented care; and of public health initiatives skewed towards medical interventions rather than preventative approaches.
The potential of fiscal and regulatory changes (like regulation to lower the salt, sugar and fat content of food) to reverse engineer society towards healthier development. However, this will need to overcome powerful resistance from both big corporations and sometimes even the medical community (with most doctors trained and employed to treat illness, using medication or surgery, rather than to pursue public health initiatives to prevent illness).
The increasing privatization of global health, with the capacity to decide what is relevant in global health in the hands of a very few powerful institutions and decision makers. These decision makers tend to pursue an acute care approach while searching for a 'magic bullet', rather than realistic measures to prevent chronic disease. Sick Societies quotes advocates from Ghana who ask, ‘How is it that HIV, with a national prevalence of 3.2% in Ghana gets multi-million dollar funding from Ghana’s development partners, while hypertension, with a national prevalence of 28.7% is ignored.’
This comes at a time when food industry support for and investment in nutrition science is weak when compared to other industries, with 1 – 2% of sales pa spent on research and development, compared with 15 – 20% for the pharmaceutical and biotechnology industry. And a time when, ‘Agriculture policies and practices have inadvertently prioritized yield, resiliency traits, appearance or shelf life above environmental impact and nutritional outcomes.’
A social movement is needed to move prevention of chronic disease up the political agenda. Lessons can learned here from successful social movements in areas such as climate change, HIV/Aids and civil rights.
Health information can help but it is competing with a deluge of marketing for less healthy options and can even widen health inequalities, depending on the capabilities and resources to convert this knowledge into behaviour. Knowing that something is a risk to your health may not be enough, if for instance, you are ‘self medicating’ with alcohol or tobacco to cope with anxiety, stress or depression. In this case it is the chronic stressors creating the depression or anxiety which need to be addressed first. And living from pay day to pay day (the ‘dictatorship of the present’) means it may prove much harder to act on the advice than if you are economically well off and find it easier take a longer term perspective.
A recurring premise is that people make choices but not in circumstances of their own choosing. ‘In India cell phones are now more abundant than toilets; ice cold Coca-Cola is more widespread than insulin to treat diabetes; and Western supermarkets and food companies are taking over traditional farmers’ jobs and markets, forcing workers to migrate to the cities or other countries in search of work, often ending up in slums.’
‘For many of us, the causes of disease are personal. Exercise would feel great, but most of the day is spent sitting in front of a computer. Eating healthy foods would be ideal, but at every turn the least healthy foods are the cheapest and easiest to find. Quitting smoking would no doubt make life better, but life is so stressful today that perhaps it is better to wait until tomorrow. To most of us, tomorrow never comes.’
Sick Societies provides an ambitious and thought provoking introduction to a growing global health crisis. It is well researched, drawing on a range of contributors and referring to over seven hundred publications and research articles. These are deployed to make a persuasive case for moving the prevention of chronic disease up the political agenda internationally and being alert to the tactics vested interests are likely to deploy to prevent or delay this.
It also provides some fascinating case studies – including examples of recession leading to reduced mortality in three very different countries (Finland, Cuba and Japan), as a result of people returning to more traditional diets, reduced alcohol consumption and reduced car use (leading to more exercise and fewer road accidents). This neatly illustrates the editors’ premise that pursuing wealth may not be good for our health.
We have a few caveats. For instance, where resources are limited, it would have been helpful to see a perspective on what the balance should be between preventing and managing chronic disease. And politically, it might have been prudent to seek to win over more members of the medical community to the benefits of prevention rather than treatment - or at least consider how such a significant culture change could be achieved. The appeal to medical students is useful but it is likely to be quite some time before today’s medical students are in a position to significantly influence the profession’s thinking.
Overall however, Sick Societies sheds welcome and much needed light on what is likely to prove the major health challenge of the 21st century – and reminds us that, as ever, prevention is better than cure.
Sick Societies – Responding to the global challenge of chronic disease Edited by David Stuckler and Karen Siegel (Oxford University Press ISBN 978 – 0 -19 -957440 -7)