Saturday, July 29, 2006

Fitter, happier, more productive

I have a bad luck condition. Out of the blue bad luck. Sometimes it irks me when I see others abuse their precious health; in the same way that it irks me that I see folks fritter vast quantities of money away simply because they have something I don’t and I imagine, if I had it, I would use it more wisely.

However, there is something that irks me far far more than that. From BBC News, Blair calls for lifestyle change.
"Ten per cent of NHS resources today are used to treat diabetes," he said. "By 2010 the estimate is that this could double.

"That's 20 per cent of the entire resources of the NHS - and it's avoidable. Three quarters of diabetics are Type 2 diabetics, and two thirds of them have a disease which could be preventable with exercise, diet and more healthy choices."

This is irresponsible rhetoric for several reasons.

The first is that such statistics are non-existent. It is possible to speculate about proportions of cases of Type 2 which may have been preventable, but sorry, there is no way that we can apply real numbers to this. We don’t understand why some folks get diabetes and other don’t; this condition is of unknown aetiology. Aetiology, Mr Blair; look it up. All we know about are risk factors.

There is almost certainly a genetic predisposition going on with diabetes. In Type 2, age is a massive risk factor - all those irresponsible folks surviving past sixty-five. There are various illnesses, surgical procedures and medicinal regimes that increase your risk. And clearly, obesity is a major risk factor or more precisely, the amount of fatty tissue in the abdominal cavity is a major risk factor. And obesity is a complex disease in itself. My two friends who developed Type 2 diabetes in their thirties were already disabled, which undoubtedly influenced the millions of individual decisions they made which may or may not have contributed to getting sick - or took those decisions right out of their hands.

How exactly the proportionate cost of diabetes could double within three and a half years, I really don't know, but we'll pretend that makes perfect sense.

Obviously, the idea behind this rhetoric is either to scapegoat and stigmatise people with diabetes or it is to persuade currently healthy people to take steps to prevent themselves getting ill in the future. We'll give the guy the benefit of the doubt...

But which of these two messages is more likely to effect your own lifestyle choices?
A proportion of people with diabetes brought it on themselves because they eat too much and don’t get enough exercise.


You greatly heighten your risk of diabetes if you continue to eat as much as you're eating and don’t start getting more exercise.

The point about most of the risk-taking we do is that it is just that; risk-taking. Nobody knows for sure they are going to get ill if they take a particular course of action.

People calculate these risks using the information available to them as well as something called the optimistic bias; because actually, we’re not natural worriers and most people would rather think that they are not going to get sick. One of the ways that this operates is that we identify and emphasise the differences between ourselves and people who have acquired illness; those people got sick because they are more stupid, lazy, careless or selfish than I am; I will not get sick.

Talk about how other people have become ill, and even people in high-risk groups will disassociate themselves from those people; well, I am overweight, but those people who got sick must have been very overweight.

Of course, however much information we have about how to look after ourselves, the day we stop taking risks is the day we die. And I believe most of us do think about this and made our decisions accordingly. I know there are things I do to make myself feel better in the short term, but which cannot be doing me much good in the long term. Included in these are the five prescription items (none of this which is keeping me alive or benefitting my long term health) as well as various dietary stuff. Hopefully you will sympathise this because I am a tragic cripple, but I don't believe that I have more on my plate than other people; for me, it is pain and fatigue, for others it is stress, time constraints, poverty, etc., etc..

Of course
some people make excuses for themselves (perhaps most of us), but since none of us can possibly determine this from the outside, we can’t make any judgement on individuals. And if we could, what could we do about it? We cannot physically prevent people from making bad choices. And we cannot punish people for their mistakes; chronic illness is disproportionate and entirely unjust as it is.

So to public health:
He argued that public health problems were "not, strictly speaking, public health problems at all".

"They are questions of individual lifestyle - obesity, smoking, alcohol abuse, diabetes, sexually transmitted disease," said Mr Blair.

"These are not epidemics in the epidemiological sense - they are the result of millions of individual decisions, at millions of points in time."
Some more words to look up. Epidemiology is the study of incidence and distribution of disease. Obesity (ICD-10 E65-68), alcoholism (ICD-10 F10-19), diabetes (ICD-10 E10-14) and the different varieties of sexually transmitted infections are all diseases. Statisticians might legitimately describe these things as endemic - or epidemic if the incidence is increasing. These can also be described as public health problems.

Smoking and “alcohol abuse” (if this phrase is taken to mean binge-drinking, for example) are indeed matters of individual lifestyle. The prevalence of these behaviours within our culture have an effect on our health. These can also be described as public health problems.

Poverty is also a major risk factor for almost every life-threatening disease there is. That can also be described as a public health problem. Just thought I would throw that in.

I know, I know. What is a Prime Minister to do?

First off, you can't blame sick people for being sick. Nobody chooses to be ill, certainly nobody deserves to be ill and the most anyone can say about almost any condition is that a person took a gamble and lost. There may have been quite compelling, even logical reasons for taking that gamble, or it might have been a very stupid thing to do. Every case is individual but nobody who is losing their sight through diabetes or gradually running out of oxygen because of a lifetime of smoking deserves to be told or treated as if they brought it on themselves.

Secondly - and perhaps more to the point - you can't blame the short-comings of the NHS on people who live less than healthy lifestyles. Talk to doctors, nurses and health-service managers - of course there will be exasperated by certain patients who refuse to mend their self-destructive ways, but my experience suggests that this won't be the first thing that comes to mind.

Thirdly, to improve the health of the nation...

Personally, I am in favour information which explains the precise relationship between cause and effect. Ideally, we would all get excellent human biology in schools and then everything else would be easy after that. Public information has tended to be ineffective because it fails to explain stuff; when a child is doing something naughty, it is sensible to say "Stop that at once!" but if you want the child to refrain from doing it again, you must explain why it is a bad idea.

More is perhaps less with public health information. Too much information, especially information which has the potential to cause worry, tends to confuse people. What's more, the message must be got across that people can get sick regardless of lifestyle. This week there has been a study to show that people with dark skin are more likely to die of skin cancer. One of the reasons for this may be that all this emphasis on the tan-craving pale folks who are more likely to get skin cancer may have lead us to believe that darker skins are not at any risk at all.

The NHS needs... uh, don't ask me.

All sorts of social problems, which can be affected by legislation, lead to unhealthy lifestyles. Poverty and social inequality being a very big deal - okay, so it is relative; few people are starving in this country, but then by the same token, there's nothing wrong with our nations health compared to most other parts of the world.

Otherwise, I think we should try to appreciate what we have got, but also appreciate its fragility. Illness and death are inevitable parts of life - the latter, defines what life is. If people value their lives and value their health, then they will act accordingly - or not, but since there's nothing any of us can sensibly do to coerce one another, that's something we'll just have to accept.


Lady Bracknell said...

As a selfish, wasteful, irresponsible, burdensome and costly diabetic who clearly and inarguably brought the condition on herself entirely through her own actions (or inactions), Lady Bracknell cannot thank the Goldfish enough for this sterling blog entry.

Anonymous said...

Right on, Goldfish. Such comments as Blair's seriously worry me. I think that, faced with the black hole that is NHS finance, he and his advisers have decided on a deliberate policy of "blame the victim" in order to justify rationing. A sinister agenda.

A cursory study of history might benefit Mr B also, where he will find that a similar situation arose during the 19th century with regard to the welfare system then in place, the Poor Law. When the finances of that got out of control, a parallel movement arose to blame paupers for their poverty and refuse them help.

That said, I would make one tiny point. There are circumstances in which a doctor's reluctance to treat a condition, although it appears to be moralistic, may not be so. Take coronary heart disease and smoking, for instance, or alcoholism and liver transplants.

Mary said...

Well put.

Although... I do find it upsetting when people blast their bodies to bits with drugs or alcohol or generally being a muppet, and I really wish we could somehow fund the NHS by taxing stupidity.

The Goldfish said...

Yes, I acknowledge that for some people, in some circumstances, dynamic treatment is like a loan to a debtor you know isn't going to pay up.

And yes, people can be very muppet-like. I must say that when it comes to individuals close to me, I can be far more critical - after all, I have an investment in them being okay myself.

The thing I object to are these sweeping generalisations and the resulting prejudice (and dangerous ignorance) in the public perception.

Mary said...

"the resulting prejudice (and dangerous ignorance) in the public perception."

Absolutely. How this gets reported in the gutter press will have the most impact on that though.

I have a couple of diabetic friends and relatives, and if for instance they have a car breakdown they generally mention to the operator that they are diabetic and therefore have to know how long the wait will be because they need to know if they have to go and seek food or not.

We can just see these remarks leading to "it's your own fault you're diabetic, just have to go hungry for a couple of hours mightn't you?" rather than the sympathetic response they've experienced so far.

BloggingMone said...

Great post. The health system in Germany is about to collapse because it is getting too expensive. We do not have a NHS, but health insurances. For reasons beyond my understanding the number of helath insurances is roughly about 1000, each living in marble palaces (honestly!) and keeping up a huge bureaucracy. 14% of my wages go to them, in addition the same is paid by my workplace. Boss and I, for example, are paying 997,00 Euros a month. Still the health insurances do not have enough money. Now there will be changes. Thank goodness there are even a few effecting the insurances.
Apart from that politicians are blaming people for getting sick. Diabetis was on the agenda, smokers will have to pay an additional fee in future, acohol abuse wasn't mentioned so far.
Research has revealed in the meantime that the pharmacy industry could cut down the costs to an enormous extend by selling products not cheap, but just reasonably priced. They have run completely out of controle and charge whatever they like to please their shareholders.
The only thing I wasn't quite opposed to is charging people extra if they decide to do high risk sports, such as mountain climbing, speed boat racing or whatever. I also agree that if people leave the tracks and go skiing wherever they like, digging them out of an avalanche and flying them to hospital in a helicopter should be on their own expenses.

Sally said...

Excellent post Goldfish. Please consider send it to Tony with a copy to your MP. Worringly, Tony is just the tip of the iceburg; beneath him are the script writers, ministers of health, department heads, researchers, political advisors - all contributing to what Tony is going to believe next.

The Goldfish said...

Bloggingmone, for all the faults of the NHS, I strongly believe it is the best system. Of course, economic has to come into what can be done for whom, but the idea of this depending on personal wealth in any circumstances is just abhorrent to me. It exists to some extent now - I can't get an NHS dentist, and I can't afford to pay for a private dentist, so I haven't been to a dentist in seven years (fortunately, I have good teeth and haven't had any problems).

Anonymous said...

Hi Goldfish!

I suspect that you'll find that Tony Blair is just reflecting a trend in public opinion. And given that it is the public that fund the NHS through their taxes, why shouldn't their democratic opinion be taken into account in deciding the treatment that is provided. Yes, it brings an element of moral judgement into the provision of treatment, but that is the disadvantage of any system of public provision - if those that pay for it start to think that it's being used irresponsibly, or that the amount of wealth redistribution is too high, eventually they will act and pull the plug as is their democratic right. As always, the price of freedom is eternal vigilance. In this case, for those of us who need someone to subsidise our lifestyles, the price of the freedom that that subsidy brings is making sure that we and our fellow subsidisees are seen to be acting responsibly by the subsidisers.

Public opinion won't always stay the same as it is now, and when it does change, the change will happen pretty fast - I've seen it happen. Playing the victim card won't work because the public will have already decided that they're the ones being victimised. For this reason, I welcome Tony Blair's comments since, given the blatant disregard that many British people seem to have for their health, presumably because they assume that the NHS will be there to pick up the pieces, it should improve my chances of continuing to receive the subsidy that I need.

BloggingMone said...

Goldfish, I agree. I would like to have an NHS over here, which would save a lot of costs. But I wasn't very clear in my description of our health system. We pay according to oure income, but the money is spend equally on everyone, independant of what someones has payed in the first place. It goes into a kind of pool, so to say. It is just like the NHS, but we have about 1000 little NHSs, which is rediculous and a waste of money.