Turning the Health World Upside Down

There’s a growing acceptance of the links between health, wealth and wider society. Not just the impact of wealth inequalities on measures like life expectancy. But the importance of fixing the underlying social causes of medical problems, rather than just administering the medicine and wondering why the patient doesn’t get better.

It’s convenient to frame this as a Third World problem. And while it is, it’s also a problem within and between developed countries. For example, people from one area of Glasgow (in Scotland) live a decade longer than people residing in another area of the same city, in spite of (theoretically) having access to precisely the same medical expertise.

A most basic analysis of Great Britain (and much of the developed world) reveals an organizational chasm, which most people are not prepared to cross: For example, medical services and social care provision are completely different activities – separate funding, differing structures, responsibilities, professional bodies. Even though individual “patients” shift seamlessly between them. It’s an organisational situation made worse by the difficulty both groups seem to have integrating with anything – in my experience (largely failing to integrate public transport into health and social services), a combination of:

  • The intrinsic (internal) complexity of the service itself, which leaves little mental capacity for also dealing with “external” factors.
  • The tendency to be staffed by those with people-orientated skills, who are often less able to think strategically or in abstract.
  • The dominance of the government, with a natural tendency towards bureaucracy and politicized (irrational) decision making.

Complexity is the biggest problem, because it keeps getting worse: More (medical) conditions and treatments to know about, higher public expectations, greater interdependence between different cultures and areas of the world. Inability to manage growing complexity ultimately threatens modern civilization – it will probably be one of the defining problems of the current age. So adding even further complexity in the form of understanding about “fringe issues” is far from straightforward.

Beyond these practicalities lurk difficult moral debates – literally, buying life. Public policy doesn’t come much harder than this.

Into this arena steps Nigel Crisp. Former holder of various senior positions within health administration, now a member of the UK‘s House of Lords. Lord Crisp’s ideas try to “kill 2 birds with one stone”: For the developed world to adopt some of the simple, but more holistic approaches to health/society found in the less developed world, rather than merely exporting the less-than-perfect approach developed in countries like Britain.

To understand Crisp’s argument requires several sacred cows to be scarified: That institutions like the National Health Service (which in Britain is increasingly synonymous with nationhood, and so beyond criticism) are not perfect. That places like Africa aren’t solely populated by people that “need aid” (the unfortunate, but popular image that emerged from the famines of the 1980s). That the highest level of training and attainment isn’t necessarily the optimum solution (counter to most capitalist cultures). If you’ve managed to get that far, the political and organisational changes implied are still genuinely revolutionary: To paraphrase one commenter, “government simply doesn’t turn itself upside down”.

While it is very easy to decry Nigel Crisp’s approach as idealistic, even naively impractical, he is addressing a serious contemporary problem. And his broad thinking exposes a lot of unpleasant truths. This article is based on a lecture Crisp gave to a (mostly) medical audience at the University of Edinburgh. And the response of his audience. The lecture was based on his book, Turning the World Upside Down: the search for global health in the 21st Century (which I have not read).

Problem, What Problem?

In the last century, Western medicine did rather well – dramatically increasing life expectancy. So it isn’t immediately clear that the system which delivered this needs to be changed. In practice, the demands placed on the system are changing, as is the wider environment in which the system functions. For example:

  • Greater global interdependence – diseases travel rapidly between continents, staff and knowledge move (fairly) freely between countries.
  • Lower tendency for (especially educated) patients to follow medical instructions, coupled with the reluctance of the medical profession to accept such an exercise of free will.

The (medical) service was built to provide treatment, but the need is also for supporting social care. The basic model of provision is becoming the problem.

While Crisp expects to see solutions emerge from many areas (like pioneering individuals, disability groups, or other industries), he focused on “global health”: Using insight from other countries.

Global Health

Sub-Saharan Africa has 10% of the world’s population, 25% of the diseases, 3% of the resources, and 1% of the medical staff. It isn’t hard to start identifying problems. Fundamentally, there aren’t enough medical staff being trained: For example, Ethiopia trains a hundred doctors each year, while the United Kingdom trains thousands. Both countries have similar population sizes.

However, places like Africa have advantages:

  • They provide space to innovate: Developing world solutions are often simpler and cheaper than First World solutions, yet can be just as effective. Both treatments and policies have transferred from developing, to developed markets.
  • Traditions often accentuate the role of family and community in activities. The result is that issues like health, education and economic activity are naturally linked. Health isn’t seen as remote from “other things”, in the way it often is in developed countries.
  • People are trained for a job, not a profession: Individual skills tend to be more specific, and consequently much cheaper and quicker to train. In contrast, Western medics tend to be highly (and expensively) trained in a broad range of procedures, and then spend much of their working lives not using most of their skills.

Nigel Crisp’s logic is that knowledge and methods should transfer from the developing world to the developed world. Part of a much more genuine, mutually beneficial trade than currently exists: Co-development, not international development.

Mutually beneficial, because this allows ideas to move around globally, experience to be shared, individual minds to be opened. And, of course, it neatly addresses issues in both the developed, and developing medical systems.

Perspective

In subsequent debate, a member of audience referred to the “profoundly disabling” impact of First World medicine. The tendency for Western populations to be maintained on a cocktail of drugs and treatments, that often limit patients’ ability to live full lives. Also evident in perceptions of “illness” between countries – very few 40-year olds in the developed world consider themselves ill, in contrast to the United States (in particular), where almost the entire older-adult population seems to be being treated for something. It triggered the kind of audience reaction video doesn’t record: The slow realization that, actually, Western medicine might not have it all right.

It’s a sentiment echoed in the tendency of high income countries to ignore the work of bodies like the World Health Organization. By cynics like me, who see organisations like the (UK) National Health Service as national institutions, more than services. By the population, who appear to be rapidly losing trust in the wider medical profession. Or even in the ultimate utilitarian criticism – the perpetuation of life for the purpose of expending further medical resources on the perpetuation of life.

That the medical profession might have something radically new to learn, could be [sorry] a tough pill to swallow. That they might have something to learn from primordial Africa, could be quite a revelation. Yet the bigger problem is likely to be us, because the wider population also has to accept the benefits of an inherently global approach. And we may be far more reluctant.

De-Complexity

Equally fascinating was the audience’s apparent reluctance to accept reduced technical training for most medics. It would be easy to dismiss this as job protection – doctors clearly prize their status in wider society, which diminishes once most have been relegated to specialist nurses or social workers – even if the current profession is too “top heavy”, with large numbers of people that are over-qualified for the work they actually do. Rather, I suspect it goes to the core of a society that strives to “be better”. That values more training, better experience – and so is reluctant to accept second best, even when second best may be entirely adequate.

Yet less extensive training appears to be a requirement for individuals to broadened their experience into other areas. Wider social issues, practice in Zambia, whatever. Less complexity in an individual’s core trained skill creates mental space to consider other complex elements. The implication is that an element of de-skilling is required to handle greater complexity. And logically – since few (if any) individuals retain a full range of skills – there is then far greater requirement for team, community, society based methods of operating. The risk, of course, is that this simply narrows the “silos” (focus) of job-orientated professionals even further, and/or requires greater management.

I’m reluctant to dismiss the notion of learning from developing world, because there clearly are things that can be learnt. However, I’m unconvinced that more simple approaches can be transferred into the developed world, while still maintaining the benefits of the complex structures already found here. There may not be an equilibrium where the “best of both worlds” can co-exist. Rather, the adoption of less complicated methods might result in a less complicated overall society: One that does not support the types of scientific advances that have historically emerged from places like Europe, and generally haven’t emerged from places like Africa.

This isn’t a simple problem, yet I continually encounter it…