How changing behaviour saves lives
If we get hurt, we go to the hospital. But what if we could avoid getting hurt in the first place? Jack James is a professor in the Psychology Department at RU and the author of a recently published book called “The Health of Populations: Beyond Medicine”. According to Dr. James, healthcare is dominated by strong beliefs that biological understanding is the foundation for promoting health and preventing illness.
“What this book shows is that despite the importance of biological understanding, health in all societies is more the result of behavioural and social causes than biomedical factors. There is a large gap between the claims made in support of medicine and the actual success of medical care. Optimal health will be achieved only by replacing medicine as the dominant form of healthcare to being an adjunct to preventive behavioural, legislative, and social interventions.”
By way of illustration, Dr. James refers to the enormous global burden due to death and injury from road accidents. “If a person is injured in an accident, their chances of recovery are greatly improved if they are immediately taken to hospital and given emergency medical care. This is where medicine is best able to demonstrate its lifesaving potential. This reality could lead us to conclude that medicine is the best approach we have for dealing with road trauma and therefore we should invest heavily to ensure the highest possible level of access to medical care.”
The power of behaviour
“However, we need to ask, what causes road accidents in the first place. It is obvious that only the tiniest fraction of accidents is caused by biomedical factors. Almost all road-accident death and injury is caused by behaviour, including speeding, drink driving, mobile phone use, not wearing a seat belt, fatigue, and so on, all of which can be relatively easily addressed through legislation and traffic control technology. Sweden has the world's lowest rate of road accidents, and what it has done to achieve that record can in principle be duplicated almost everywhere. Doing so would avoid a million deaths worldwide every year and save tens of millions of people from injury. Nothing that medicine can do now or in the future has any prospect of matching those results.” Rather than spending ever-increasing amounts on medical rescue, it is more logical to increase expenditure on prevention.” There are obstacles though, including the ‘identifiable victim effect'. The tragedy of an accident evokes strong emotions including sympathy for those injured and gratitude by those who are helped to recover. “We do not see the people for whom death and injury have been prevented, and therefore we have less reason to feel grateful. These tendencies can get in the way of doing what is logical and necessary to prevent tragedy.”
Where medicine falls short
“Another illustration of failure due to medical dominance in healthcare is the fact that in the 1960s, WHO warned of a looming epidemic in noncommunicable diseases like cancer, heart disease, diabetes, and Alzheimer's. That epidemic is now upon us, which could not have happened if medicine were truly effective. Interestingly, some high-income countries experienced reductions in heart disease during the last decades of the 20th century. For example, based on known trends there were 70,000 fewer deaths from heart disease in England in the 20 years from 1980. The question is what was responsible for that substantial saving of life. Was it due to innovation in medical healthcare? Improvements in medicine did indeed contribute to extra years of life, but only to an amount of 20% of the total benefit. The larger benefit of 80% was due to changes in behaviour related to ways of living. The most important factors were reduced smoking and changes in diet, including increased consumption of fruit and vegetables and less intake of salt.
More recently, improvements in heart health have stalled, showing again that improvements in medicine are not capable of reversing overall trends. It is likely that the trend towards less physical activity is one cause of the continuing high levels of heart disease, and without change the situation may be worse in the future. For example, recent studies show that 80% of children and adolescents worldwide satisfy the definition for being physically inactive.”
Individual freedom vs. the „nanny“ state
So, who should be changing our behaviour, is it up to us? According to Dr. James, the power sits with us as individuals, but also with local authorities and with central government. “Let´s take smoking. Individuals can decide to quit. However, we do not live in a bubble, so we tend to make decisions based on what's happening in the environment around us. If certain behaviour is common where I live and work, I'm more likely to do it. This is why legislated workplace smoking bans have been so successful. They have led to a population shift away from general acceptance of smoking towards an anti-smoking norm. This was resisted by the tobacco lobby, which was successful in Denmark in arguing that smoking is an ‘expression of individual freedom'. The opposite happened in Sweden. What is the result? The death rate from lung cancer in Denmark is twice that for Sweden and Danish women have the highest rate of lung-cancer death in Western Europe.” As the two populations share a similar gene pool, the difference is due to smoking behaviour, including passive smoking where death and disease are caused even among individuals who choose not to smoke.
A local example - Icelanders should not increase access to alcohol
In light of this, we are interested in hearing Dr. James‘ views about the much debated alcohol-laws here in Iceland, and whether current access to alcohol by way of the existing network of liquor stores should be extended to allow the sale of alcohol in grocery stores. “The scientific evidence leaves no room for doubt. The current laws should not be changed. Increased availability leads directly to increased health problems such as cirrhosis of the liver and increased social problems such as public disturbance and violence in the home.” James gives us an example: “Liver cirrhosis has almost quadrupled in the United Kingdom since a policy of deregulation was introduced which made alcohol easier to access. As with smoking, the alcohol lobby argues for ‘individual freedom' and against the ‘Nanny State'. But these are empty arguments that merely reflect vested interest. The current network of liquor stores ensures that Icelanders are free to buy and drink alcohol in whatever quantity they choose, so what good will be achieved by changing the existing law? In fact, Iceland has an opportunity to demonstrate international leadership by allowing all adults the freedom to buy and drink alcohol while retaining the existing reasonable limits on access. Any relaxation of those limits can only have negative health, social, and financial effects for everyone, including those who choose not to drink.
The point Jack James makes in his book is that more commitment to prevention and less increase in expenditure for biomedical healthcare will lead to healthier populations at lower cost. “Science shows that medicine is a poor solution for the major problems of health.”