When I teach young doctors in Amsterdam about responding to NCD (non-communicable disease) in low and middle income countries, I ask them how they would allocate 100 units of resource. I give them four buckets.
One bucket is for treating people with established disease: patients with heart attacks, strokes, cancer, and chronic obstructive pulmonary disease. The second bucket is for treating metabolic risk factors, such as hypertension, hyperlipidemia, and raised blood glucose. The third bucket is for acting on the four risk factors—tobacco use, poor diet, physical inactivity, and the harmful use of alcohol—recognising that many of the interventions will be political, actions like raising the price of tobacco. The fourth bucket is for working on social determinants, such as poverty, housing, globalisation, and urbanisation. I ask the doctors not only how they will distribute their resources, but what they will do with the resources.
This “game” is now being played out at a global level as decisions are made on the Sustainable Development Goals (SDGs). An intergovernmental open working group is preparing the SDGs and has just published its first draft. The global decision makers have many more buckets to consider than the young doctors in Amsterdam in that there are 17 goals and 164 targets.
Goal 3 is: “Ensure healthy lives and promote wellbeing for all at all ages,” and underneath it are 13 targets (see under Goal 3). Some of these goals and targets are extremely aspirational—like ending the epidemics of AIDS, tuberculosis, and malaria, and “ending poverty in all its forms everywhere.” The Lancet has called some of these fairy stories.
Jocalyn Clark—a former editor on The BMJ and PloS Medicine, a keen observer on global health now working in Dhaka, and a friend of mine—has recently published four articles that have much to contribute to the debate over which goals and targets to prioritise, and how the young Amsterdam doctors should allocate their resources.
Clark, a public health scientist by background with training in sociology, argues forcefully that global health is being medicalised. Medicalisation is the process whereby the biomedical model dominates discussions on health—meaning that health is seen as “freedom from disease” and there is a bias towards “reductionism, individualism . . . and the technological.” Such thinking would lead the Amsterdam doctors to put their resources into the first two buckets, treating disease and metabolic risk factors. The results of medicalisation can be that normal behaviour (perhaps shyness) is pathologised, individuals (patients) are disempowered, and social problems are depoliticised—for example, a response to the pain of unemployment is to give people antidepressants rather than work politically to provide meaningful jobs.
Medicalising the global response to NCD
One of three cases that Clark explores in making her case is NCD, exactly the problem the Amsterdam doctors are considering. The draft SDGs also include: “By 2030 reduce by one third premature mortality from NCDs through prevention and treatment, and promote mental health and wellbeing.” The clumsy wording suggests that the mental health goal was tacked on at some point. The emphasis on mortality—rather than quality of life—has a medicalising feel, and “through prevention and treatment” has a still stronger feel.
The first problem that Clark sees with medicalising the global response to NCD is that there will be an emphasis on individuals rather than on public health interventions. She’s right that doctors tend to be more concerned with individuals (not a bad thing if you’re one of the individuals), and they can be disparaging of public health.
Nigel Crisp, once chief executive of the NHS and author of Turning the World Upside Down, argues that the hegemony of clinical medicine has undermined public health. It’s also true that public health interventions tend to reduce inequalities in that they benefit all, whereas individual interventions tend to increase inequalities because they are least likely to reach the poorest. But Clark may fret too much because the World Health Organization’s list of “best buys” for countering NCD is dominated by measures like increasing the tax on tobacco and alcohol and reducing their availability—because these measures have strong evidence behind them, are likely to have a big impact, and cost little compared with most clinical interventions.
Clark worries that doctors and medicine dominating the agenda means that action on social determinants is crowded out or forgotten. Plus doctors are expensive and raise costs. They are also concentrated in cities when most poor people are in rural areas. Clark thinks that using nurses and community health workers instead of doctors is really just “medicalisation light,” but what seems scandalous to me is that across the world doctors tend to oppose nurse prescribing and the use of community health workers—even when there are no doctors.
One of the failures of those concerned about NCD is that there is nothing like the patient or consumer community that there is around AIDS and HIV, and Clark thinks that their voices may be drowned out by doctors and industry. Although there is agreement that responding to NCD requires a “whole of government, whole of society” approach, Clark (like many others) is inclined to see industry more as part of the problem than part of the solution.
This is certainly true for the tobacco industry, but in a world where a billion people are hungry and a billion people obese, the food industry has to be part of the solution as well as part of the problem. Similarly, the pharmaceutical industry has to have an important role when there is strong evidence that cheap, off patent drugs can dramatically reduce recurrence rates in those who have had heart attacks and strokes, and yet less than 5% of all those in the world who might benefit actually receive the drugs.
Medicalisation and universal health coverage
Clark also discusses the medicalisation of mental health in one of her articles, but the article that has attracted most attention is that on universal health coverage. There is huge global enthusiasm for universal health coverage, and the Lancet has called it “an irrepressible right,” but Clark is right to raise anxieties.
Everybody would like a world where everybody has access to healthcare, but one important problem is the tendency to conflate healthcare and health. The world leaders who gather to finalise the SDGs will not be experts on health, and may easily make the mistake of thinking that health is a product of health services—when health services are really sickness services and make only a modest contribution to health. But even the director general of WHO, Margaret Chan, made the mistake of conflating the two when she said that universal health coverage is “the single most powerful concept that public health has to offer.” Universal health coverage “will not revolutionise global health, nor reduce large inequalities,” says Michael Marmot, the world’s leading expert on the social determinants of health. Plus, as Clark writes, “healthcare can cause harm, be wasteful, and be costly.”
Then, argues Clark, universal healthcare is reductionist and “excludes the social and political determinants of health.” Worse still, it can provide an excuse for inaction on unpopular steps, such as raising the price of tobacco, despite the substantial health benefits that such steps can bring.
A deficiency in the debate over universal healthcare is that most attention is paid to the financing of basic packages of healthcare and not enough to access, staffing, knowledge support, responsiveness, equity, quality, and safety. Clark worries too that the drive for universal health coverage may provide a bonanza for private companies “transforming the healthcare needs of a population into specific commodities, defined by (mostly medical) experts, for economic markets.” The poor, aged, and chronically sick may be neglected by private systems. I share Clark’s insistence that the marginal must be covered, but it seems to me that when the vast majority of care in Africa and South Asia is provided by the private sector a publicly provided system like the English NHS is unachievable, even if it was politically desired. Governments may do best to restrict themselves to funding and regulating healthcare and putting more emphasis on public health.
I hope that Clark’s papers will be carefully considered as politicians move to making final decisions on the SDGs, and I have encouraging news for her. When I ask the young doctors in Amsterdam to make their choices on where to allocate resources, they usually allocate much more to action on social determinants than to health services—despite being medical doctors. The politicians may well behave in the same way.
Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.
Competing interest: RS has worked with Jocalyn Clark at both The BMJ and PLoS Medicine, and is now chair of the board of trustees of icddr,b [formerly the International Centre for Diarrhoeal Disease Research] where she works. He also provided a reference for her application to the Bellagio Centre where she wrote the articles.