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Yesterday I unexpectedly found myself at a talk by the social epidemiologist Ichiro Kawachi on the social determinants of health. He's giving a talk at UWA tonight, it may be too late for people to go though. Audio available from here (thanks Zanchey!)
It was absolutely fascinating. Here are some somewhat unstructed thoughts based on the notes I took (on my pda, I certainly didn't go in expecting to take notes) and the printout of his slides.
Basically, the idea is that if we want to lower the prevalence of some illness we need to look at (and fix) the environmental factors driving the overall trend towards it, not focus on telling individuals how to "stop making themselves sick". He looked specifically at why England is healthier than America despite the fact that americans spend way more on healthcare (and tend to drink and smoke less), and within that at what's causing the "obesity epidemic". It was pretty much exactly the thing I was looking for the reconcile the somewhat contradictory ideas that (a) There's an obesity epidemic and (b) there's not that much individuals can do to change their weight (so how are we all getting fatter?) It also very much suits my pinko socialist tendencies :)
He quoted a lot of the english epidemiologist Geoffrey Rose, who talked about how things like weight work as a bell curve, and rather than seeing the morbidly obese people at the tail end as the problem (and exceptions compared to "normal healthy people"), we should be trying to move the whole population towards a lower mean weight and better "normal".
A point he made, which I've never seen before, is that you can't blame American's poor health and low life expectancy on bad healthcare or racism, since even if you restrict your analysis to white people, the richest (and most insured) americans are still sicker than the poorest brits. Also that it takes ten years for immigrants (of any ethnic background, including himself :)) to get up to american levels of obesity, showing it's not a genetic problem either.
People like to think of health in the economic model of peronal responsibility, individual agents making rational decisions based on cost benefit analysis. But this ignores the huge effect the environment they live in has on how they make their choices: the unhealthy choice may be the most rational in their context, and to fix that you need to change the context.
And the group whose environment is most often the most limiting, are the disadvantaged and the poor. If all the local parks are full of broken equipment and drug dealers, it is rational not to let your kids go out to play and get some exercise. If it's a choice between eating junk food or not affording enough to eat, it's rational not to get your five fruit and veg.
Another example he gave is smoking: education campaigns about the dangers of smoking are important, but they've had much more success banning smoking indoors (so that it's no longer a social boon) and (bizarrely) increasing OHS standards in manufacturing workplaces (why avoid the toxins of smoking if you inhale them at work anyway?)
His suggestions for the future were to figure out what things in society push people towards unhealthy choices, and target the producers of the toxic environment, with some suggestions:
Unfortunately he didn't talk about the australian context for these ideas at all.
One thing he said which I found a bit problematic (when asked about targetting disadvantaged groups) is that while he doesn't want to gloss over the huge effects of racism in America, most of the health problems black americans suffer are largely related to their class status, and that anyway he avoids talking about race on principle becuase it's so polarising: rich white people are willing to support programs to help "poor people", but not to help "black people" (whose problems they tend to blame on laziness etc)
Now I agree that if you erase poverty then you'll have fixed a lot of non-white people's health problems. But sometimes their experience really is very different to that of poor white people ( in aboriginal communities, for example), and needs specific attention, and it's very easy for programs which are theoretically for all *insert group here* to be disproportianately geared towards a subset (ie urban, and thus mostly white, poor people) And of course, even rich non-white people have problems with racism, though I don't know that their health is much worse.
Something he said is "If you have a broken arm don't go to a social epidemiologist", ie that obviously this sort of analysis is useful but can't be the whole of your health policy. And knowing your society is making you sick isn't much help in trying to fix your own individual heralth, though I guess it is a sort of comfort.
Anyway, overall it was really interesting. I don't know that it would be quite so exciting for those with a stronger background in health policy, but the audience on the whole seemed quite happy with the talk.
It was absolutely fascinating. Here are some somewhat unstructed thoughts based on the notes I took (on my pda, I certainly didn't go in expecting to take notes) and the printout of his slides.
Basically, the idea is that if we want to lower the prevalence of some illness we need to look at (and fix) the environmental factors driving the overall trend towards it, not focus on telling individuals how to "stop making themselves sick". He looked specifically at why England is healthier than America despite the fact that americans spend way more on healthcare (and tend to drink and smoke less), and within that at what's causing the "obesity epidemic". It was pretty much exactly the thing I was looking for the reconcile the somewhat contradictory ideas that (a) There's an obesity epidemic and (b) there's not that much individuals can do to change their weight (so how are we all getting fatter?) It also very much suits my pinko socialist tendencies :)
He quoted a lot of the english epidemiologist Geoffrey Rose, who talked about how things like weight work as a bell curve, and rather than seeing the morbidly obese people at the tail end as the problem (and exceptions compared to "normal healthy people"), we should be trying to move the whole population towards a lower mean weight and better "normal".
The problems of sick minorities are considered as though their existence were independent of the rest of society. Alcoholics, drug addicts, rioters, vandals and criminals, the obese, the handicapped, the mentally ill, the poor, the homeless, the unemployed, and the hungry, whether close at hand or in the Third World - all these are seen as problem groups, different and separate from the rest of their society.
This position conveniently exonerates the majority from any blame for the deviants, and the remedy can then be to extend charity towards them or to provide special services. This is much less demanding than to admit a need for general or socio-economic change
A point he made, which I've never seen before, is that you can't blame American's poor health and low life expectancy on bad healthcare or racism, since even if you restrict your analysis to white people, the richest (and most insured) americans are still sicker than the poorest brits. Also that it takes ten years for immigrants (of any ethnic background, including himself :)) to get up to american levels of obesity, showing it's not a genetic problem either.
People like to think of health in the economic model of peronal responsibility, individual agents making rational decisions based on cost benefit analysis. But this ignores the huge effect the environment they live in has on how they make their choices: the unhealthy choice may be the most rational in their context, and to fix that you need to change the context.
And the group whose environment is most often the most limiting, are the disadvantaged and the poor. If all the local parks are full of broken equipment and drug dealers, it is rational not to let your kids go out to play and get some exercise. If it's a choice between eating junk food or not affording enough to eat, it's rational not to get your five fruit and veg.
Another example he gave is smoking: education campaigns about the dangers of smoking are important, but they've had much more success banning smoking indoors (so that it's no longer a social boon) and (bizarrely) increasing OHS standards in manufacturing workplaces (why avoid the toxins of smoking if you inhale them at work anyway?)
His suggestions for the future were to figure out what things in society push people towards unhealthy choices, and target the producers of the toxic environment, with some suggestions:
- Make cities/suburbs have a high "walkability"
- tax unhealthy food and subsidise healthy food (just taxing makes people too poor to eat)
- Get in interventions as early as possible in people's lives ie healthy food at childcare centres
- Work with environmentalists to create a sustainable environment (same overall goals)
Unfortunately he didn't talk about the australian context for these ideas at all.
One thing he said which I found a bit problematic (when asked about targetting disadvantaged groups) is that while he doesn't want to gloss over the huge effects of racism in America, most of the health problems black americans suffer are largely related to their class status, and that anyway he avoids talking about race on principle becuase it's so polarising: rich white people are willing to support programs to help "poor people", but not to help "black people" (whose problems they tend to blame on laziness etc)
Now I agree that if you erase poverty then you'll have fixed a lot of non-white people's health problems. But sometimes their experience really is very different to that of poor white people ( in aboriginal communities, for example), and needs specific attention, and it's very easy for programs which are theoretically for all *insert group here* to be disproportianately geared towards a subset (ie urban, and thus mostly white, poor people) And of course, even rich non-white people have problems with racism, though I don't know that their health is much worse.
Something he said is "If you have a broken arm don't go to a social epidemiologist", ie that obviously this sort of analysis is useful but can't be the whole of your health policy. And knowing your society is making you sick isn't much help in trying to fix your own individual heralth, though I guess it is a sort of comfort.
Anyway, overall it was really interesting. I don't know that it would be quite so exciting for those with a stronger background in health policy, but the audience on the whole seemed quite happy with the talk.
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You might have some luck emailing him, he was pretty friendly and interested in sharing his ideas.
I came accross one of his articles online yesterday and of course can't find it again, but I did find this book of his.
I wonder if talking about this counts as work or slacking off? :)
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Who auspiced the talk? Some people like to bring out a transcript, is all - if it was an ABC public lecture or something, there might be one available.
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*wanders off idly past the OED*
Seriously, I have never seen that usage before. It intrigues me, tho', especially with the below comment re use in VET. Maybe it's an APS thing.
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Huh.
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Anyway, good luck tracking it down.
And that's Dr sqbr to you :)
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If Dr Sophie knows who organised the earlier talk I might be able to find the recording for that too.
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I really should write up my thoughts on obesity from having spent the last eight weeks on a surgical unit that specialises in gastric banding and the like.
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I'd certainly be interested in hearing your thoughts, so much of the discussion about obesity is overlaid with all this social stuff that has very little to do with the real medical situation. I mean, it's only recently that I learned that lipsouction makes you "fatter" internally (where it matters, healthwise)(*), all the stuff I've heard against it has been about how vain and lazy it is (plus being generally dangerous just because it's surgery)
(*)This is my very vague medically ignorant understanding of what a dr friend said :)
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Britain does notably badly on a lot of health care, etc - but overall, its not so much that the US is worse than Britain overall (though it is), but that the US spends a vast amount more on health care overall, and is STILL worse than Britain. Britain has its problems, but they are comparitively minor compared to the vast brokenness of the US system.
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Also, it's interesting to note that for the poor in western societies processed food provides greater calories than fresh food. So if you're struggling to afford food, you might be better getting a frozen pie than a shepherds pie.
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*blinks*
No, that's bizarre! (Very not social epidemiologyish though) It does put the idea of an obesity "epidemic" in a different light :)
Also, it's interesting to note that for the poor in western societies processed food provides greater calories than fresh food. So if you're struggling to afford food, you might be better getting a frozen pie than a shepherds pie
Yes, exactly.
*gets on a soap-box*
You statement that "there's not that much individuals can do to change their weight" is an absolute falsehood. Your destiny, particularly as an affluent member of a free society, is in YOUR OWN HANDS. The existence of unhealthy pressure from large economic and social factors is not a reason to stop trying - it is why you must try harder.
Re: *gets on a soap-box*
Absolutely, I conflated a few ideas. This talk was aimed at public health policy makers and specifically aimed at answering the question "What government policies will have the best results for the overall health of the country?", not "What should we as individuals do to be healthy?". He made a point of saying that social epidemiology is important but only one part of a good public health policy, and that it's also important to educate and encourage personal healthy actions in the public.
The "there's not that much individuals can do to change their weight" statement was a continuation of the thoughts on the Fat Acceptance movement from my previous post, and something I'm not 100% convinced of, I just find it an interesting POV to look at the world from since it's so at odds with the message we are usually given.
Having looked up statistics etc in a small way, it does seem to be true that overwhelmingly most diets fail, and that most people who lose weight gain it all back within 5 years. Which doesn't mean people shouldn't try: just because the odds are against you doesn't mean you won't succeed, and anyway "failure" will will probably still make you healthier. But it's something I personally find it helpful to keep in mind: if it's true, what does that mean for me and where do I go from there? (I like asking myself difficult questions :))