30 Mar, 12 | by BMJ
Tuberculosis used to be (and sometimes still is) the great scourge, causing death and disease on a global scale and changing the course of human history over millennium. It is often called consumption—partly because the disease seems to “consume” the body.
Those who do not learn from history are destined to repeat it. The evidence strongly suggests that the biggest global health threat we now face is due to another sort of consumption: unfettered use and disposal of resources that leads to unmanaged climate change; something we understand much more that we care to admit, and certainly in enough detail to warrant much more action. But, as the Nobel Laureate Sherwood Rowland says, “What’s the use of having developed a science well enough to make predictions, if all we’re willing to do is stand around and wait for them to come true.”
We continue to ignore the evidence despite the compelling evidence that addressing it helps address most of the other current challenges for health systems in mutually reinforcing ways (demography, societal behaviours, expectations and aspirations, cost control, resource use, empowered public and patients…)—a very convenient truth indeed. In our (very) finite wisdom, however, we choose to ignore both the evidence and the more obvious actions. If you’ve read this far, you’re probably asking yourself “well, what can I do?” Well, I ask this question frequently of policy makers, managers, chief executives, clinicians, the public, and myself. Here are a few areas where health professionals can show example. Not taking any visible action (especially when the NHS and health professionals are trusted so much) sends out a dangerous message.
1. Set an example by moving better. (Never in human history have we moved our own bodies around the world so much without actually needing or making the effort to move our own bodies.) As George Bernard Shaw (may have) said: “Whenever I see an adult on a bicycle, I have hope for the human race.”
2. Help more people eat better. With one billion people unwell by being underfed and one million people being unwell by being overfed there seems to be an issue of distribution, access, and social justice here.
3. Help more women take more informed control over their fertility. This may help address reaching a more sustainable population too.
4. Value pharmaceuticals much more highly. Like any valuable resource, reduce unnecessary demand, prescribe carefully, and re-use drugs that have been checked for safety. We now know this is more publicly acceptable.
5. Treat every unplanned admission to a hospital as a sign of system and financial failure until proved otherwise. Not because they often are, but because it realigns incentives and cultures in a more healthy and sustainable way. If you think that we need to be paid to do this, then we should pay hospitals and others for outcomes not activity i.e. for keeping people healthy and independent in the community. We should change the culture by curtailing payments when preventable diseases increase and avoidable admissions rise. If partners fail to grit the pavements, which then overloads A&E, then the relationships and incentives need realigning with partners.
6. Let’s not treat death as failure. Let’s treat hospitalised, expensive, undignified, unempowered death as failure.
7. Let’s remember what humane, holistic, and compassionate care really is, and train ourselves and others to actually do it. And let’s develop our emotional and sustainable intelligence in the same way as we claim to have developed our cognitive intelligence. (Richard Smith recently wrote a blog on this)
8. Lastly, let’s consume less and connect more. Being a meaningful and a fulfilled member of our community must surely be an important determinant of health.
The recently published (third) NHS England carbon footprint has shown that the procurement fraction now accounts for 65% of the total carbon footprint. It’s what we buy that matters. Really good healthcare may start to be characterised by “less is more.” We should only be providing it (and using it) when all other (usually preventative) interventions have been exhausted. We should reward systems for outcomes related to health, not processes related to healthcare. Unnecessary healthcare is inconvenient, unpleasant, unsafe, unaffordable, and unsustainable. There may even be a time when less healthcare will lead to more health; when health is properly defined as being able to “lead a life one has reason to value.” (Amartya Sen: Development as Freedom. OUP, 1999.)
So, like Koch, and the understanding of the TB bacillus, we are at an equally important juncture of history, where “consumption” is again likely to change the course of history—causing avoidable death and disease on a global scale. This is the acquisitional, not the microbiological, sort of consumption. This is about buying things we don’t need, with money we don’t have, to satisfy a craving which we shouldn’t indulge. The credit crunch is about unacceptable borrowing from the future. The climate crunch is about unacceptable stealing from the future. Despite our relative intelligence we do not appear to be smart enough to make the transition from a frontier species to a steady state species. But there is just one important difference this time round. Until Robert Koch published his seminal research in Berlin, the causes of death by 19th century consumption (and how we might intervene to prevent unnecessary suffering) were not understood. Today, in the 21st century, we know exactly what we are doing with the global systems that sustain a life worth living. Yet, we still choose to do very little about it. Health professionals and health systems can do a lot. When good people choose to do too little, then bad things happen. The next generation will find it difficult to understand (and forgive) why we seem so keen to forfeit our future (and theirs) by dying of consumption all over again.
David Pencheon is a UK trained public health doctor and is currently director of the NHS Sustainable Development Unit (England).