Originally published by the Association of Health Care Journalists.
Why is it that, when we talk about health promotion, we still get stuck talking about smoking, diet and exercise when we know that social factors have the biggest influence on health outcomes?
Health care is but one element of what makes the biggest difference in health outcomes – social factors play a far more significant role. Income and its distribution, education, employment, social supports, housing, nutrition, and the wider environment — what we have come to know as the social determinants of health – are the most powerful predictors of wellness and longevity. This has been understood for centuries, and empirically validated in recent decades with study after study demonstrating significant inequalities in health outcomes between wealthy and disadvantaged populations.
Yet political conversations about health still tend to fall into familiar traps. When we talk about health, we return as if by reflex to doctors and nurses, hospitals and pharmacies. This is an understandable impulse, as these tend to be the sorts of activities that fall under the mandates of ministries or departments of health, the sections of government that we would imagine are most responsible for keeping us healthy.
This idea that health has to go beyond health care is not a new one, as evidenced by the age-old adage that an ounce of prevention is worth a pound of cure. Since the 1970s there have been significant developments in two related fields. The first, preventive medicine, has largely emphasized interventions such as vaccination and early screening for treatable disease. The second, health promotion (often considered a subset of the former), has its primary focus on non-clinical choices that can be taken to avoid illness. These choices can be made at the level of the individual, or at the level of public policy.
In other words, health promotion can, and should, be about promoting decisions at every level – personal, social and political – that will have the greatest impact on reducing illness and improving health outcomes.
The Trinity Trap
As a result of this shift in understanding, more writers and policy-makers are able to avoid thinking only of health care when discussing health outcomes. Nods to prevention and health promotion have become a regular element of public discourse on health.
Unfortunately, that analysis often falls prey to a second trap. When speaking of prevention, people tend to have a difficult time moving beyond what is often referred to as the “holy trinity” (1) of health promotion: smoking, diet and exercise.
"The problem is not that we talk about these individual choices. The problem is that that’s where we stop."
Now this is not to say that these are not important factors in health outcomes. Stopping smoking is perhaps the most effective means available to an individual to expand their lifespan and improve their well-being. I work in an inner-city clinic, and despite the fact that most of my patients are dealing with factors high up on the list of social determinants, I never neglect to counsel on smoking cessation and frequently discuss diet and exercise at length.
The problem is not that we talk about these individual choices. The problem is that that’s where we stop, and in doing so, we miss addressing the factors that will have the greatest impact.
So why is it, then, when we know that the social determinants of health are what matter most, that we get stuck in the Trinity Trap?
Some of this may be a matter of health promotion being a victim of its own success. Victories in informing public opinion have had great influence in improving diet and exercise and decreasing smoking, at least in certain segments of the population. Health behaviours tend to improve with rising incomes, as social factors not only determine health, they also determine behaviour. In fact, there’s been some argument that health promotion has actually increased health inequality, as the messages are most effective at reaching those in least need of help. That’s not an argument to stop promoting individual choices, but it does demonstrate the limitations of that approach on its own. These successful campaigns may play a role in crowding the field, acting as a go-to set of prevention points that block us from thinking in greater depth about what really keeps people healthy.
Health is most easily imagined through stories, whether our own or those of patients dealing with specific illnesses. The solutions are accordingly most easily imagined at the same level. Someone has poorly controlled diabetes? It’s far easier to consider what they choose to eat each day than it is to address the prevalence of food insecurity in their region and the macroeconomic policies that influence what choices are available. It’s so much simpler and quicker to think of personal agency rather than societal agency. As a result, even public policy measures tend to focus on influencing individual choices through awareness campaigns and incentives.
From trinity to TINA
Perhaps the greatest reason this trap is so successful is because the alternative, looking at what would need to change to dramatically influence health, is so complicated. Looking at the list of determinants of health – income, education, employment, etc. – we see these are clearly not the purview of the Department of Health, but really encompass the whole of government. As such, politics is the field of endeavour with the greatest impact on health outcomes. If we think back to the core purpose of our public decision-making bodies, and the legitimacy on which their authority rests, above all their role should be to improve our health and well-being. Political decisions can and should improve our health, and they should be evaluated based on the degree to which they are successful in doing so.
Yet, in today’s discourse, a narrow and economistic outlook seems to trump any attempts to address those social determinants. Our ability to realize what government is truly for, to improve the lives of people, is hampered by the terms of discussion. Whatever brilliant ideas may come forward to improve lives and health, whatever arguments may be brought forward, they are quickly dismissed if they counter the current frame. That frame is informed to a great extent by the “TINA” frame: you may not like the system the way it’s working now, but There Is No Alternative, so get on with your individual lives and let the market decide.
Changing the landscape
To imagine a different approach, it’s helpful to turn to a classic public health parable:
Imagine you’re standing on the edge of a river. Suddenly a flailing, drowning child comes floating by. Without thinking, you dive in, grab the child, and swim to shore. Before you can recover, another child comes floating by. You dive in and rescue her as well.
Then another child drifts into sight... and another... and another. You call for help, and people take turns fishing out child after child. Hopefully before too long, some wise person will ask: Who keeps chucking these kids in the river? And they’ll head upstream to find out.
"Upstream is a movement intent on changing the conversation."
Every time we have to clean up an environmental disaster, every time a young person winds up in jail, every time people have to take medicines to make up for the fact that they couldn’t afford good food, we’re suffering from the results of downstream thinking.
Thinking upstream means making smarter decisions based on long-term outcomes. What better goal than creating the conditions for all people to enjoy true health — complete physical, mental, and social well-being? And what better measure of its success than the health of those people?
An upstream approach also allows us to stop seeing investment in people as a cost. When we take into account the economic and social benefits of a healthy, educated population, we see that by doing nothing to address the factors that make people sick, we ensure that more and more kids will fall into the river, and that many of them will drown.
A new organization launched last year in Canada seeks to bring forward a new way of talking about politics. Upstream is a movement intent on changing the conversation. It aims to make the mainstream look upstream, helping citizens to demand a healthy society, and to understand the best ways to get there. This sort of re-framing effort is necessary if we’re to open up enough space to discuss policies that would make real differences in income inequality, access to quality education and affordable housing, and help maintain sufficient environmental integrity to safeguard human life.
Asking tougher questions
The Trinity Trap allows journalists and policy makers an easy way to avoid difficult questions by focusing on individual failings rather than collective failings. If we step back and embrace optimal health as a meaningful goal for our society, then it’s clear why a myopic focus on smoking, diet and exercise is a trap to be studiously avoided. Sticking with a wrong diagnosis because it’s more convenient is a terrible way to take care of a patient. Talking about individual choices without considering the socioeconomic circumstances in which those choices are made is an easy way to keep people sick.
(1) S. Nettleton, “Surveillance, Health Promotion and the Formation of a Risk Identity,” in M. Sidell, L. Jones, J. Katz, and A. Peberdy (Eds.), Debates and Dilemmas in Promoting Health (London: Open University Press, 1997), pp. 314-24.
Ryan Meili is a Family Doctor at the Westside Community Clinic in Saskatoon and an assistant professor at the College of Medicine, University of Saskatchewan, where he serves as head of the Division of Social Accountability and director of the Making the Links Certificate in Global Health. He is the author of A Healthy Society: How a Focus on Health Can Revive Canadian Democracy (Purich 2012) and serves as the founding director of Upstream: Institute for A Healthy Society.