Kent Buse: Healthy societies—fixing systems not people

Feminists of all stripes and genders point to the patriarchal, gender unequal, and at times, misogynistic “system” that discriminates against women and other groups burdened by inequalities in power—holding them and society back. The system is shorthand for our social institutions and interests, and the ideas and norms that sustain them. System fixes to promote gender equality include measures such as legislating equal pay for equal work, mandatory split parental leave, or rewarding firms that ensure gender parity on their boards.  

It is time we apply the same logic of fixing “the system” when it comes to health and illness. Take a step back and look at the health system. Most societies spend the bulk of their health budgets on treatment and care for people once they become ill. A very limited amount is invested in health promotion and prevention within those healthcare systems. This approach is short-sighted and failing—governments are not taking advantage of opportunities to prevent disease.  

It is short sighted in the sense that it has long been known that it is the environments in which people live, work, and interact that determine their health or ill-health. Specifically, it is people’s access to things like decent housing, decent working conditions, and decent food that make or break good health outcomes at a societal level. Over the past two decades a wealth of evidence has confirmed the importance of these “social determinants of health”—with inequalities in society and their consequence—including in access to safe recreation, quality education, paid parental leave, and other determinants—being the overriding factor in whether people live with good health and wellbeing or fall sick and die prematurely. Sometimes these are called structural determinants to reflect the broader ways that societies are organised and governed. It follows that there are commercial, political, and diplomatic determinants of health—for the latter one need not look any further than the donation of surplus covid-19 vaccines from powerful countries. 

This way of thinking about how society conditions and shapes people’s chances for health or illness was vividly portrayed by Vito Russo, an activist living with HIV. In 1988 he told a rally: “If I’m dying from anything, I’m dying from homophobia. If I’m dying from anything, I’m dying from racism. If I’m dying from anything, it’s from indifference and red tape, because these are the things that are preventing an end to this crisis…. And, especially, if I’m dying from anything, I’m dying from the sensationalism of newspapers and magazines and television shows, which are interested in me, as a human interest story—only as long as I’m willing to be a helpless victim, but not if I’m fighting for my life.”

Understandably, AIDS activists set their sights on accelerating research on treatment and later treatment access, but their movement equally sought to address the wider environments which exposed people to HIV infection. And as a result, they campaigned, among other things, for decriminalisation of drug use, sex work, and homosexuality as well as for safe injecting sites, housing and keeping girls in school to protect them from HIV. 

Much like feminism, the AIDS movement has sought to fix the system—through programmes such as harm reduction for people who use drugs. Sadly, the AIDS movement has been relatively exceptional in its success. For the most part, society tends to focus on treating sick people, not on creating healthier societies. This is easily explained by prevailing interests—defined as who stands to gain from this predominant focus on disease rather than health—including the commercial interests of the insurance and medical industries and private care providers. 

But as Vito Russo alluded to, our approach to health is also sustained by the prevailing ideas around what needs to be fixed. The narrative is stuck on promoting ideas of “personal responsibility,” “poor personal choice,” and “unhealthy behaviours.” For example in relation to obesity, “solutions” are aimed at changing individual behaviours, including through the provision of more consumer choice, rather than on calling for system-wide change to build, sustain, and encourage healthier environments for all. Thus, we see an emphasis on the production and marketing of “healthier lifestyle choices” involving less of everything (alcohol, sugar, salt, fats) alongside an increasing privatisation and commercialisation of opportunities for activity and exercise. This has resulted in the growth of fitness and wellness industries into multi-million dollar opportunities to make a profit from peoples’ understandable concerns to live healthy lives in increasingly unhealthy environments. Meanwhile, even in schools of public health, remarkably little attention is paid to the biggest challenge of all: fixing the broken system rather than the people in the system.

Nonetheless, might there be reasons for optimism. 

The first lies with the World Health Organization (WHO) which, under the current Director-General, raised the salience of healthier populations. Among other things, the present global programme of work places the goal of “one billion more people enjoying better health and wellbeing” alongside two other corporate priorities. A new department of social determinants of health was created as part of a wider organisational transformation. The recent World Health Assembly resolution on the social determinants of health provides a signal from its Member States to move the agenda forward. This includes a mandate to develop an operational framework with recommendations on future action. This aims to strengthen the capacity of countries to address the determinants and, importantly, create greater UN collaboration on an agenda, that if it is to be successful, must look beyond the healthcare sector. Many delegations welcomed the resolution as did key civil society organisations. The World Obesity Federation stressed the need for a systems approach and, in relation to malnutrition, for example, to integrate efforts across health, food, transport, water, sanitation, education, and economic systems.

There are good reasons to believe that the timing of this renewed interest in looking upstream to turn off the tap of illness couldn’t be better. Covid-19 has served as a wake-up call on the importance of health to societal wellbeing, and to the reality that one’s life circumstances to a large extent determine one’s exposure to the virus. The pandemic has shown up the limits to healthcare systems—even those of the very richest countries. The WHO’s ambition therefore might be falling on fertile soil.

But, we shouldn’t pretend that it will be an easy lift. The treatment paradigm is as pervasive as sickness industries. Here too, however, WHO has put its foot forward by establishing a new department on the commercial determinants of health. 

While the agenda may appear daunting, what is needed first and foremost is a change of mindset. 

It is time to shift our focus to fixing the broken system, not just trying to fix the people within the system. The Elige Vivir Sano Programme in Chile is a great example of a government-led initiative that adopts an intersectoral and systemic approach to facilitate access to healthy diets, physical activity, and wellbeing to prevent obesity. Health for All will not be achieved until countries around the world follow suit and develop concrete actions to fix our sick environments. 

Kent Buse is director, Healthier Societies Program, The George Institute for Global Health and serves of the Policy and Prevention Committee of the World Obesity Federation.

Competing interests: none declared.