{"id":50650,"date":"2021-07-13T20:54:42","date_gmt":"2021-07-13T19:54:42","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=50650"},"modified":"2021-07-13T21:41:08","modified_gmt":"2021-07-13T20:41:08","slug":"kent-buse-healthy-societies-fixing-systems-not-people","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2021\/07\/13\/kent-buse-healthy-societies-fixing-systems-not-people\/","title":{"rendered":"Kent Buse: Healthy societies\u2014fixing systems not people"},"content":{"rendered":"

Feminists of all stripes and genders point to the patriarchal, gender unequal, and at times, misogynistic \u201c<\/span>system<\/span><\/a>\u201d that discriminates against women and other groups burdened by inequalities in power\u2014holding 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.\u00a0\u00a0<\/span><\/p>\n

It is time we apply the same logic of fixing \u201cthe system\u201d 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 <\/span>once <\/span><\/i>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\u2014governments are not taking advantage of opportunities to prevent disease.\u00a0\u00a0<\/span><\/p>\n

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\u2019s 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 <\/span>evidence<\/span><\/a> has confirmed the importance of these \u201csocial determinants of health\u201d\u2014with inequalities in society and their consequence\u2014including in access to safe recreation, quality education, paid parental leave, and other determinants\u2014being 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 <\/span>commercial<\/span><\/a>, <\/span>political<\/span><\/a>, and diplomatic determinants of health\u2014for the latter one need not look any further than the <\/span>donation<\/span><\/a> of surplus covid-19 vaccines from powerful countries.\u00a0<\/span><\/p>\n

This way of thinking about how society conditions and shapes people\u2019s chances for health or illness was vividly portrayed by Vito Russo, an activist living with HIV. In 1988 he <\/span>told<\/span><\/a> a rally: \u201cIf 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\u2026. 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\u2014only as long as I’m willing to be a helpless victim, but not if I’m fighting for my life.\u201d<\/span><\/p>\n

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.\u00a0<\/span><\/p>\n

Much like feminism, the AIDS movement has sought to fix the system\u2014through programmes such as harm reduction for people who use drugs. Sadly, the AIDS movement has been relatively exceptional <\/span>in its success. Fo<\/span>r the most part, society tends to focus on treating sick people, not on creating healthier societies. This is easily explained by prevailing interests\u2014defined as who stands to gain from this predominant focus on disease rather than health\u2014including the commercial interests of the insurance and medical industries and private care providers.\u00a0<\/span><\/p>\n

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 \u201cpersonal responsibility,\u201d \u201cpoor personal choice,\u201d and \u201cunhealthy behaviours.\u201d For example in relation to obesity, \u201csolutions\u201d 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 \u201chealthier lifestyle choices\u201d 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\u2019 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.<\/span><\/p>\n

Nonetheless, might there be reasons for optimism.\u00a0<\/span><\/p>\n

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 \u201cone billion more people enjoying better health and wellbeing\u201d 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 <\/span>resolution<\/span><\/a> 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 <\/span>stressed<\/span><\/a> 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.<\/span><\/p>\n

There are good reasons to believe that the timing of this renewed interest in looking upstream to turn off the tap of illness couldn\u2019t 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\u2019s life circumstances to a large extent determine one\u2019s <\/span>exposure<\/span><\/a> to the virus. The pandemic has shown up the limits to healthcare systems\u2014even those of the very richest countries. The WHO\u2019s ambition therefore might be falling on fertile soil.<\/span><\/p>\n

But, we shouldn\u2019t 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.\u00a0<\/span><\/p>\n

While the agenda may appear daunting, what is needed first and foremost is a change of mindset.\u00a0<\/span><\/p>\n

It is time to shift our focus to fixing the broken system, not just trying to fix the people within the system. The <\/span>Elige Vivir Sano<\/span><\/a> 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.\u00a0<\/span><\/p>\n

Kent Buse<\/b> is director, Healthier Societies Program, The George Institute for Global Health and serves of the Policy and Prevention Committee of the World Obesity Federation.<\/span><\/em><\/p>\n

Competing interests<\/strong>: none declared.\u00a0<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

Feminists of all stripes and genders point to the patriarchal, gender unequal, and at times, misogynistic \u201csystem\u201d that discriminates against women and other groups burdened by inequalities in power\u2014holding them […]<\/p>\n

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