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HEALTH [image, unknown] Reform and self-help

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Footless and fancy free?
‘Get healthy’, we urge ourselves. And jogging, aerobics and health foods are how most of us go about it. But Jeannette Mitchell warns that this fun-filled pursuit of individual health is an elaborate con-trick that distracts us from the more fundamental causes of illness.

NO-ONE knows where good health comes from. The more you look, the less clearly you see. But in the last ten years there has been an upsurge of interest in the problem of how we can be healthy. The present vogue for health has many strands.

There is the official strand. Following pressure from the International Monetary Fund on the British Government to cut back public spending, the House of Commons Expenditure Committee recommended that money could be saved through more prevention of illness, especially through self-help. The present Conservative Government has followed the Labour Government in spending ever larger sums on anti-smoking and physical fitness health education campaigns. Guilt is the core of the method. The smoking pregnant women has now to contend with the knowledge she is also killing her baby.

Then there is the popular strand: running, swimming, keep fit, dieting, aerobics. There are TV programmes, abundant advice in the newspapers and on the back of cereal packets, hundreds of best. selling books, thousands of classes and a boom in shorts and running shoes. Exercise clothes and everyday fashion are becoming increasingly indistinguishable. Footless tights, running shoes and track suits have all been incorporated into what we wear normally. Then there is the strand that comes from criticisms of Government policy and ruling ideas. Health cannot be improved by individual action, we argue. Look at the factories and the housing estates. It is noise, noxious chemicals, accidents at work, pollution from cars and industry, lead in the air, junk food, high in salt, sugar, fat and chemicals. It’s damp and overcrowded housing and the isolation of tower blocks. It is shiftwork, exhaustion and the strain and isolation of looking after young children. It is unemployment. It is not having the money to buy decent food, holidays, heating and adequate housing. It is living with chronic stress, at work and at home. It is not being able to give up smoking, drinking or cut down on over-eating because our society generates too many pressures. The whole organisation of work and domestic life damages our health.

Today, the view that much ill health, particularly cancer and heart disease, could be avoided by changes in lifestyle has become so widespread it is regarded as themselves a disservice. They also burden the community with the cost of caring for all this self-inflicted disease.

Care in Action, the Conservative Government’s policy statement on the health service published in 1981 puts it this way: ‘The prevention of mental and physical ill health is an area in which the individual has clear responsibilities. No-one can wholly escape illness or injury, but there are plenty of risks to health which are within the individual’s power to reduce or avoid. Too many endanger their health through ignorance and social pressures’. The argument becomes most horrible when it is used to account for the vast class differences in death rates and levels of illness in society. Even the crudest statistics reveal the pattern: if you live in a council house and don’t own a car you are nearly twice as likely to be dead before you reach 65 than if you are an owner-occupier in a two-car household.

The view that the lower classes are killing themselves through over-indulgence and self-abuse is the prevalent explanation for the class pattern of ill health in medical circles.. Doctors moan that their working class patients will not give up smoking or change their eating habits. Even the Labour Government defined the problem as one of ignorance.

The 1977 White Paper Prevention and Health talked authoritatively of the ‘problem of communicating effectively with people in social classes four and five’. And it’s an argument which suits the Conservatives down to the ground.

But this approach to ill-health —blaming the victim — completely absolves food manufacturers, polluters, employers and landlords of their part in destruction of health. And it makes no attempt to understand why in a society where there seems no hope for the future — people sometimes choose to drink, smoke, eat what they feel like and sit in front of the telly.

Knowledge about what makes us ill is based on studies correlating our ill health with our exposure to certain foods, chemicals, noxious substances in the air, housing conditions and so on. This has yielded remarkable and thought-provoking results. We now know, for instance, that at least 75 per cent of cancer is environmental in origin, and therefore in principle preventable. But it is also increasingly clear that the quality of our general health cannot be simply reduced to the extent of our exposure to specific measurable environmental nasties.

For example, one study of civil servants’ heart attacks found there were four times as many deaths among men in low-paid jobs like porters and messengers, than among senior bureaucrats. True, men at the bottom had smoked more and taken less exercise than the men at the top. But even when this was taken into account, three in four deaths of the men at the bottom remained unexplained. There was something else going on.

It has been known for hundreds of years that whether we get ill is not only dependent on the pathogens we are exposed to, but our body’s resistance. If you are run down you get everything that’s going. What factors bear on our levels of resistance, however, gets far less discussion than it deserves. But exhaustion, boredom, powerlessness and loneliness emerge again and again.

Health is not a virtue. A look at our present society reminds us that health is not only an attribute of the just. The people at the top the most senior civil servants, the judges, the university professors, the doctors and leading businessmen, the controllers, decision makers and exploiters have by far the best health. And it is an unpleasant thought that the reason for this is much more likely to do with their power their job satisfaction, sense of control over their lives, emotional support from wives and secretaries, time for leisure and recreation than with foregoing the pleasures of the flesh.

So the notion of health an entity in itself dissolves. And we are left with everyday life. The routes to better health cannot be distinguished from what we want anyway: control over our lives, satisfying work, excitement, time for recreation, space for personal autonomy, opportunities for supportive and loving relationships, decent food, a non-toxic environment, holidays, space for children to play, warm and unclaustrophobic housing. There are no short cuts to the healthy life. It is back to the old political dilemmas about what kind of social change we want and how to make it. It is a social movement which is both encouraging and frightening. Encouraging because it shows that people haven’t given up on trying to change their lives. It’s frightening because the diet/smoking/lack-of-exercise view of illness is winning hands down.

As the crisis deepens, the forces damaging our health — through unemployment, alienating work, low incomes, loneliness, and fear of violence are becoming stronger. Yet the dominant explanations for our troubles lead us away from examining society and towards ever greater self blame.

Jeanette Mitchell is author of What is to be done about health care to be published by Penguin in April 1984.

La Riforma Sanitaria
Wayne Ellwood reports on Italy’s attempt
to turn the health system on its head.

Since 1970 Italy has been rocked by a series of social earthquakes. In the homeland of Roman Catholicism divorce was introduced, abortion and contraception were legalised, a new family code was passed and regional government was instituted.

A sweeping health reform, the Riforma Sanitaria , has continues this upheaval, creating a streamlined national health service, closing psychiatric hospitals and abolishing the powerful insurance companies which had previously dominated Italy’s medical system. ‘We are looking at a system which has been completely turned on it’s head’, says Dr Bruno Pacagnella, leading advocate of the new health service in the Venezia region. We’re no longer talking about just caring for the sick. We’re talking about protecting the health of the people. Health is no longer just a matter of physical illness. It is also about social, economic and environmental factors.’.

Passed in 1978 after years of debate, the new Health Reform Act was an attempt to restructure completely a hopelessly inefficient system. The key to overhauling the old system was shifting the focus away from doctors and hospitals. Health services were integrated with other social services and professionals in both areas were expected to work together under the auspices of new bodies called Local Health Care Units.

Each Unita Sanitaria Locale consists of a number of ‘communes’ (the traditional Italian political divisions) and all regional and local authorities are elected members of each commune council.

A single Health Unit is broken into smaller Health Districts, each one designed to serve about 10,000 inhabitants. Family Counselling centres are staffed by teams of professionals: a social worker, a nurse, a psychologist and a gynaecologist, for instance. A community clinic might have a midwife, a nurse, a doctor and a physiotherapist. Doctors themselves are legally prohibited from having more than 1,500 patients and are seem by the new law as having ‘community’ responsibilities. In the Venezia region of 4.5 million people for example, different areas have focussed on alcoholism, dental care and tobacco addiction.

Eventually each Health Care Unit is to have only one hospital. In the Venezia regional the plan is to cut 8,000 hospital beds over the next three year and to replace them with what Dr Pacagnella calls ‘primary level services’. Between 1980 and 1981, 16 private hospitals and two public ones have been closed down completely. More dramatic was the closure of the country’s psychiatric hospitals in 1981, a move without precedent in any Western nation. There are still psychiatric departments in ordinary hospitals but thousands of former patients have been integrated back into the community.

Not surprisingly, most opposition to the new system comes from doctors and hospital administrators. Both are reluctant to give up power. Before 1978, hospitals were autonomous institutions run without any kind of public input. Now Local Health Units manage their own hospitals along with all other health services.

Medical school are another problem. Italy opened university doors wide open under student pressure in the earl 1070s. As a result the country is vastly over doctored: an average of one MD to every 250 people. There are thousands of unemployed doctors – but a drastic shortage of qualified nurses, social workers and medical technicians. Reform of the medical schools is being hotly debated on the Italian Parliament. But as yet the country’s hidebound medical establishment is stubbornly ignoring the new reforms and had been slow to include preventive medicine and community education in the curriculum.

The medical establishment is not the only barrier. Many Italians are still hooked on high-technology, drug-oriented medicine. Costly private hospitals and doctors are still sough out by the wealthy and the desperate. One Chianti doctor says it is common for friends and neighbours to have a special collection for someone with a severe illness, raising money to send the patient to a private clinic in Germany, the US or England.

But despite financial setbacks and bureaucratic opposition, the Riforma Sanitaria has revolutionized the previos patchwork system of administration and payments. Since 1978, dozens of large private insurance companies have been cut out of the system. Where there were 200-300 different administrations, there is now just one at the national level setting fees, salaries and standards. At the same time, because all regional and local health authorities are elected, the control and direction of each Health Unit is very much a local affair.

‘What we have here’, says Dr Pacagnella, brushing his hand across the map of Italy on his office wall, ‘is a very deep and extended revolution. To develop a culture foe health is quite different form developing a culture for pathology. And the lines have now been drawn.’

With a report from Dr Hugh Faulkner in Chianti, Italy

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New Internationalist issue 127 magazine cover This article is from the September 1983 issue of New Internationalist.
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