Richard Smith: Rediscovering public health through global health

Richard SmithThese days I spend lots of time in low and middle income countries, and as I think more about their health problems and less about the endless reorganisations of the NHS, I begin to see the world very differently.

Recently I was asked to give the Redfern Oration to the Royal Australasian College of Physicians, and I chose as my topic “Rediscovering public health through global health.” Unfortunately I never got to Australia to deliver my oration because of a family illness. But one consequence is that a video is available of my talk in which with a rather lugubrious tone but some useful slides I describe my ten lessons on rediscovering public health through global health.

Because I can’t believe that anybody could bear to watch an hour of me I’ve edited the video into the ten lessons. You can find them at and can watch, copy, and use them should you so wish. In the rest of this blog I summarise briefly my ten lessons.

Lesson one: Modern clinical medicine is as out of control as the banks and is unaffordable globally.

I deliberately started provocatively and make my case both by describing what I see as futile procedures within medicine and by showing data projecting forward the rising costs of health care. Interestingly, the rising costs are driven not so much by the aging of the population or by raising patient expectations but mostly by new technologies and medicine’s ability to do more to fend off death.

Lesson two: Inequalities in our world are gross and need to be tackled.

Everybody knows this, but I wonder how many people feel it. Did you know that Africa has 25% of the global disease burden but only 3% of health care resources and 1% of health workers? North America, in contrast, has 3% of the disease burden but 25% of health care resources and 30% of health workers. Does that not make you feel uncomfortable if you are a health worker in a developed country?

Data from the WHO report on the social determinants of health show both that inequalities between the developed world and SubSaharan Africa are getting worse and that it is possible to make a rapid difference to inequalities—often through measures like providing potable water or increasing enrolment in primary education. Sadly evidence from Britain also shows that it is also possible to spend a great deal of money (£21 billion) trying to reduce inequalities and fail completely.

Lesson three: The Victorians eventually couldn’t live with the difference between rich and poor, and we got income tax with substantial transfers of wealth within countries. We now need such transfers between countries.

At the moment most developed countries are failing to reach the United Nations target of spending 0.7% of their GDP in aid, but as the world becomes progressively smaller, more crowded, and more threatened this may change and we may achieve a substantial transfer of funds from rich countries to poor countries.

Lesson four: You can’t have healthy people without healthy places.

This is another lesson that everybody should know, but we continue to put most of our resources into treating individuals. But we achieve little if we send people back to the same unhealthy places, and, in particular, we may make things worse rather than better if we practice prevention with individuals who live in very unhealthy circumstances where, for example, exercise is impossible, fresh fruit and vegetables are unavailable or unaffordable, and the air is full of tobacco smoke. We make things worse because we achieve little and make the individuals feel like failures.

We should also remember that healthy places will begin to disappear as our planet becomes sicker. We need a healthy planet in order to have healthy places, and luckily what is good for individuals—avoiding motorised transport and exercising more and eating more fruit and vegetables and fewer animal products– is also good for the planet.

Lesson five: We may not like to think in terms of money, but we have to pay close attention to costs—returning to the utilitarian roots of public health.

If you are rich you can be profligate, but with limited resources we need to pay close attention to value for money. Doctors treating individual patients feel very uncomfortable considering the financial consequences of their actions, but it’s easier and essential at a systems and public health level. I showed a graph that illustrated that with hospitals there is no relation between cost and quality and data that a coronary artery bypass costs $27 000 per disability adjusted life year, whereas aspirin after a heart attack is cost saving. And reducing salt intake at a population level would cost 6 cents per person and reduce mortality by 2%.

Lesson six: How we die may make a huge difference, and there are positive signs of the compression of morbidity. We must promote the idea that death is normal and a friend.

I’ve always been fascinated by the concept of “compression of morbidity,” which says that our lives have a finite limit and that the period of poor health at the end of life may be progressively compressed. Or might we live on to be 105 or 110, spending many years demented, depressed, Parkinsonian, arthritic, needing new joints, deaf aids, and cataract operations? Clearly there are huge financial as well as human implications, but we don’t really yet know which is the more likely course as life expectancy steadily increases. I did, however, show a slide from a recent study that suggested that there was compression of morbidity—but among those with lots of education, hinting again at the possibility of widening inequalities.

Doctors have paid a lot of attention to fending off death, which, I fear, is why so many people experience bad deaths in hospitals. I argue that we should recognise that death is a friend, there are worse things than being dead, immortality would be unbearable, and without death every birth would be a tragedy (in some sad sense it already is). I’m a great fan of Michel de Montaigne, who in his essay “To philosophise is to learn how to die,” writes:  “Let us disarm him [death]  of his novelty and strangeness, let us converse and be familiar with him, and have nothing so frequent in our thoughts as death.”

Lesson seven: New challenges need new ways of thinking and behaving.

Even in rural Bangladesh chronic diseases now account for 80% of deaths. This is true the world over (apart from the poorest countries in SubSaharan Africa), and yet we still have health systems that are designed to deal with acute conditions. In the US two thirds of the spend of Medicare is on people with five or more chronic conditions. On the video I show a table from a Scottish report that summarises neatly how health systems need to change, in particular to being community and team based rather than hospital and doctor based,

Lesson eight: ideology can get in the way of progress.

We often don’t recognise our ideological biases, but they go deep. I illustrated what I believe to be ideological biases by using the example of the polypill, a single pill with five components (three anti-hypertensives at half dose, a statin, and folic acid) which if everybody took everyday from their 55th birthday might reduce heart attacks and strokes by 80%. Most public health practitioners hate the idea because it suggests to them that people might carry on living unhealthy lives and simply take a pill. But isn’t this an ideological bias?

Lesson nine: developing countries don’t have to follow the disastrous path of developed countries but can leapfrog their failures.

The rapid and extensive spread of mobile phones in low income countries is one of the best examples of “leapfrogging.” There is no need to lay miles of cables. Can we achieve the same with health or will low and middle income countries inevitably have to follow the epidemic of chronic disease experienced over the past century in developed countries? Perhaps low and middle income countries can shorten the epidemic by working hard on tobacco control, particularly among women, avoiding the Westernisation of diets, and promoting exercise, perhaps through good transport policies and urban design.

Lesson ten: the rich can learn from developing countries.

Nigel Crisp concluded that the rich could learn more from the poor, and there are many examples of innovation in poorer countries spreading to developed countries. Some of these are technical innovations—like oral rehydration therapy, an artificial foot developed in India, or kangaroo care—but perhaps more are in the organisation of care and the approach to care, putting more emphasis on families, communities, and social care.

Poorer countries have a better chance of building sustainable health systems because they don’t have the inertia and vested interest of the top heavy systems built in developed countries.

Richard Smith was the editor of the BMJ until 2004.

  • sripurna basu

    Lesson three: The Victorians eventually couldn’t live with the difference between rich and poor, and we got income tax with substantial transfers of wealth within countries. We now need such transfers between countries.

    This is highly idealistic. I can't see a transfer of money from the G8 to the HIPCs just as the EU mountains and lakes of food wasn't transferred to the drought striken sub saharan Africa. I recently heard an LSE lecture where they debated whether rich countries were morally obliged to help poor countries. There is strictly no duty to help the poor although there is a case for compassion. I can't see European and American industries and economies handing over their hard earned cash to the third world countries. There is a case for redistribution of resources and industry which is already happening with outsourcing and manufacture of cheap products abroad so money is being rerouted to these countries.
    However I can see a taxation situation where a certain percentage of each countries GDP is taxed by IMF and UN to help fund poorer countries. The G8 cannot even agree on carbon level caps so I can't see them agreeing on any rates for these taxes.

  • BM Hegde

    Dear Richard,

    Congratulations. I am happy that there is at least one man in medicine who can see the larger picture of illness and health. All your ten lessons (I am yet to see the video, which I shall do sooner than later) condensed in the blog have been my pet themes for decades. Most of them could be gleaned from my rapid responses in the BMJ in addition to my books and publications elsewhere. Coming from you they will have more weight.
    We have lost our sense of proportion in patient care, both in the rich and the poor countries, thanks to the claptrap around disease care which, in addition to adding tons of money to the kitties of the different stake holders in the business, has caught the imagination of the common man, thanks to the media, both print and electronic. The latter are heavily influenced (lured) by the industry to spread the false message as far and wide as is possible. One can not practise sensible clinical medicine, which has been shown to be 100% perfect by triple blind controlled studies using even the PET scan, as every patient thinks that there is a pill or surgery for every ill. Little do they realise that there certainly is waiting an ill following every pill; in the case of some pain killers it could hit one even after a gap of five years!
    In my own experience even the poorest Indian patient demands expensive unnecessary investigations before you advice him/her! The defensive medicine practised in the US has found its way to many poor countries through the media and every one thinks that a transplant surgery can make any non functioning organ come back to life again and keep one here for ever! They have not heeded the advice of George Bernard Shaw when he wrote in his Doctors Dilemma that one should not try to live here for ever as one would not succeed. We only medicalised death; just as we have tried to medicalise the whole population through mass screening methods. 90% of the US hospital incomes come from trying to keep the dying (half dead) patients alive during the last ten days of their lives in the ICU’s. Today’s ICUs are just one way thoroughfares to heaven. Reminds me of the “hospitalism” in the nineteenth century England where a patient went to hospital en route to heaven or hell, as the case may be, never to go back home alive.
    Properly screened every one becomes a patient as we only have a statistical definition of normality. Disease mongering is a fashion these days. How can we make medicine cheaper if we continue to follow the present disease care system? Our only hope is to popularize the “wellness concept” that I had put forward years ago. Each human being could hope to remain healthy as long as one lives if only one could keep the immune guard at its best. There are hurdles on the way but we have to devise ways and means to do just that at a very small fraction of the present disease care cost. We need to popularize my idea of health expectancy in place of the conventional life expectancy. I defined health expectancy as the number of years a new born child could hope to live without the help of medicines and doctors. My hunch is that health expectancy is the longest in rural India where there are even centenarians who have never seen a doctor or a hospital.
    Richard, may I humbly submit an eleventh lesson, please? At the root of our problem is our exclusive educational system right from day one in school. Most doctors come from those strata of society, even in poorer countries, which are relatively affluent for that society. Thus educated in high end schools and colleges and then trained in five star type of teaching hospitals where the poorest of the poor who bear the brunt of illnesses are rarely seen. Even when they are there the students, far removed from the reality of the depth of poverty in their own backyard, find it hard to empathise with such hapless poor patients, leave alone trying to understand their true malady! Such students are not even comfortable communicating with the poorest of the poor as they are not used to that experience.

    Professor William Deresiewicz, from Yale University, in his paper on the disadvantages of elite education has this to say: “The first disadvantage of an elite education, as I learned in my kitchen that day, is that it makes you incapable of talking to people who aren’t like you. Elite schools pride themselves on their diversity, but that diversity is almost entirely a matter of ethnicity and race.”

    Unfortunately, poverty is increasing by leaps and bounds as seen in this recent UNPD report for India which is now considered a rich enough country if one went by the number of billionaires, thanks to our skewed economic policies of globalisation. “An analysis by MPI creators reveals that there are more 'MPI poor' people in eight Indian states (421 million in Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh, and West Bengal) than in the 26 poorest African countries combined (410 million).The new poverty measure that gives a multidimensional picture of people living in poverty, and is expected to help target development resources more effectively.” This is the recent UNDP report.

    Therefore, my eleventh lesson is the need to first deschool medical students and make them comfortable talking and understanding their unequals. Then as a second step we need to deschool society about the false propaganda that only the five star modern medicine could keep them here for ever and that every ill does not necessarily have a pill or surgery to fix it. God save mankind!