STEPHEN LEEDER. Social causes of illness are not immutable: they are amenable to change.

Jan 2, 2018

Modifying our own behaviour in health-promoting directions is sensible but for sustainable, nation-wide change we need to take action of a different kind.

Far from being a cause for despair, the insight that a lot of illness in our society derives from the environment we have created should give us enthusiasm to use the New Year to achieve better health generally.  As John Kennedy stated, “Our problems are man-made; therefore they may be solved by man”.  Or woman.

Discounting for Kennedy’s hyperbole, social determinants of illness are within our power to modify to our advantage. And while changing individual behaviour (less sugar, less salt, more exercise etc) is commendable, there are things that we can do in the community to make those individual behaviour changes easier for everyone and more likely to be sustained.

An interesting comparison between our globalised and immensely successful society and that of the Roman Empire is drawn by Kyle Harper, vice-president of the University of Oklahoma in a recent essay entitled How climate change and disease helped the fall of Rome(  He wrote:

The decisive factor in Rome’s biological history was the arrival of new germs capable of causing pandemic events.

The empire was rocked by three such intercontinental disease events. The Antonine plague coincided with the end of the optimal climate regime, and was probably the global debut of the smallpox virus. The empire recovered, but never regained its previous commanding dominance. Then, in the mid-third century, a mysterious affliction of unknown origin called the Plague of Cyprian sent the empire into a tailspin. Though it rebounded, the empire was profoundly altered – with a new kind of emperor, a new kind of money, a new kind of society, and soon a new religion known as Christianity. Most dramatically, in the sixth century a resurgent empire led by Justinian faced a pandemic of bubonic plague, a prelude to the medieval Black Death. The toll was unfathomable – maybe half the population was felled.

He points to the critical role of infectious disease and natural changes in climate in weakening the Roman Empire to near collapse. Plague, especially, was brought by rats from the east in boats carrying trading goods to Roman ports. But the authorities and population were ignorant of the causes of these afflictions and powerless to control them.  And the effects of infectious disease more generally and endemically in the crowded cities of the Empire, as urban migration surged, diminished the productivity of the nation.  The average life expectancy of a Roman citizen was in the 20s.

An immense difference exists between the knowledge possessed by our technologically advanced societies and the Roman Empire. We have knowledge that enables prevention and therapy for many of our health problems.  Our success, through sanitation, immunisation and vastly improved nutrition as well as an impressive armamentarium of medical and surgical therapies, means that our life expectancy is four times that of Rome.

But clearly we are not problem-free and we are left with a hefty rump of problems – the major degenerative disorders of diabetes, heart disease and stroke, cancer, physical trauma, musculoskeletal disorders and drug and mental illness – that are deeply troubling.  But unlike the epidemics of Rome, where nothing was known about their origin, we know a vast amount about the causes of these ailments.  And the causes, while often complex and shrouded in the economics and behaviour of our society are, as Kennedy suggests, soluble by humans. Three courses of action command our attention.

First, to move the settings on the dials that govern the way we live, the population needs to be convinced that the move has merit.  For this to happen in relation to health, the community needs first to be clear that proposed changes in our national diet and exercise patterns, for example, make sense and are potentially beneficial.

Health messaging is needed that moves beyond recommending individual behaviour change and instead points to how such things as sugar taxes, if lobbied for effectively, will enable many people to lower their sugar consumption.  The paradox is this: if lots of people decrease their consumption of alcohol, tobacco or sugar just a bit, the likely benefits are greater than if a few people go to extremes.  Advertising agencies could assist in marketing that insight.

Second, there is a place for political leadership rather than followship.  By this I mean the kind of ‘out there’ behaviour that we saw from John Howard in relation to gun control and from Neal Blewett in regard to HIV/AIDS – pushing the agenda for change.  Politicians can only go as far as the community will permit and so this point is heavily dependent on the first.

Third, the industrial and commercial interests that dominate our economic environment should be commended when they make moves to reduce the hazards in our environment – by offering food choices in our markets that are less injurious, cutting down on portion sizes in restaurants and attending to equity of access to fresh food in rural, remote and Aboriginal communities.

Simply because disease is socially determined, we are not rendered impotent in dealing with it.  If we take the correct messages from this insight and contribute to the large social changes needed for effective prevention, then 2018 will be an important year in preserving the health of our nation.

Stephen Leeder is an emeritus professor of public health and community medicine at the University of Sydney and an affiliate of the Menzies Centre for Health Policy.





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