RHP&EO is the electronic journal of the International
Union for Health Promotion and Education
|
|
|
|
General practitioners and health promotionRob Moodie and Chris Borthwick Correspondence:Dr. Rob Moodie, CEO Victorian Health Promotion Foundation e-mail: rmoodie@vichealth.vic.gov.au Publication Date: 7 December 1998 Moodie R, Borthwick, C, General Practitioners and Health Promotion. Internet Journal of Health Promotion, 1998. URL: ijhp-articles/1998/11/index.htm. Before health promotion came along in the early 1970s medicine was called the youngest science1. Doctors have been prescribing remedies for trauma and disease for at least five thousand years, but for four thousand, nine hundred and fifty of those years our prescriptions didn't work. We didn't really know the causes of disease, and the remedies we had - bleeding, for example, or purges - did more harm than good. If you were a general practitioner in London in 1850, for example, just about the only things you had in your pharmacopoeia that actually worked were opium, for treating diarrhoea, rhubarb, for treating constipation, and J. Collis Brown's Chlorodyne, which contained morphine, ether, cannabis and treacle and certainly should have had a generally cheering effect. Of course, we could always give good advice.
The doctor's advice would be much the same today although we tend to be, fortunately, a lot more careful about blaming patients. Then as now, people who ate well, took moderate exercise, and didn't smoke had better health and a better chance of survival. In Victorian times, however, the huge new cities that had been created by the industrial revolution were periodically ravaged by epidemics of infectious disease. In 1854, for example, in one London suburb, five hundred people died of cholera in ten days, and that wasn't unusual. What was unusual about that outbreak was that one general practitioner went beyond examining individual patients and looked at the outbreak at the level of the public health. He stepped out of the office, past the scores of waiting patients, and walked down Broad Street.
Dr. John Snow looked at the map of incidence of cholera, noted that there seemed to be a concentration of cases along Broad Street, hypothesised that cholera was a water-borne disease, and determined that many patients must be drinking contaminated water from the Broad Street pump. So he went out, took the handle off the pump, and provided the foundation myth of the public health movement. Since then, of course, medicine has made great strides. We can actually cure quite a number of the diseases that people come to us with. If my patient has cholera, I can now fix it (although when I was in the midst of a cholera epidemic in Eastern Sudan in 1985, and another one in postwar Iraq in 1991, cleaning up their water supply was much more important than giving everyone tetracycline). However, in the western world at least our water supplies have by now improved markedly and patients today tend not to have cholera. A large proportion of them still come in either with diseases that we still can't fix, like colds, or with conditions that we still can't really identify, like unspecific mental discomfort. We can still give them good advice - the same good advice as in Victorian times, in fact - and this advice will certainly do them good, if they follow it. Most GPs have followed their own advice, at least on smoking. The latest study of Australian GPs2 found that their smoking rates were about 4% for men and 2% for women, as against a general rate for men of 28% and 24% for women. Building on this, more and more GPs are taking up the role of offering their patients advice on healthy lifestyles - counselling, posters, pamphlets, summaries after checkups, screening, follow up. Some studies have found that clients reduced their risk behaviours on being informed by their doctor, others have not. A recent meta-analysis3 by Ashenden, Silegy & Weller found that "whilst many of the general practice-based lifestyle interventions show promise in effecting small changes in behaviour, none appears to produce substantial changes." I don't want to underplay the importance of this aspect of your work with health promotion - as Quit points out, if small changes are made in large populations, that still adds up to tens of thousands of people who have had their lives extended - but we must recognise its limitations. In part these are due to the problems of carrying out health promotion in the general practice environment. Doctors are overworked, and the medical benefits schedule does not encourage in-depth discussions of health promotion. Not all GPs engage in heath education with their patients, many of those who do, still feel rather unsure giving advice on such things as exercise that may lie outside their main area of expertise4, and many patients react poorly to people telling them what they ought to do5. While GP smoking rates are an example to all, their rate of alcohol and drug abuse is about the same6 as the general population, and the profession positively cultivates long hours, overwork and stress as a badge of commitment. And only 42% of doctors have a general practitioner of their own, and 26% have a medical condition that they feel inhibited about discussing with a doctor7. All of these things we can work on. We can also ask if we have given enough attention to advice on the positive correlates of health. In certain age groups there seems to be an established protective effect of moderate wine drinking, for example.8 It has been suggested that frequency of intercourse correlates with improved mortality rates9, although further research is needed. There is a strong correlation (for women at least) between survival and attendance at cultural events, reading books or periodicals, and making music or singing in a choir.10 Perhaps GPs (and health promotion foundations for that matter) would have more success having their advice adopted if their prescriptions were more pleasant, if we concentrate on what we can do, rather than on what we can't. In part, however, the lack of impact of health education measures may be due to the fact that the behaviour of the individual makes up a smaller part of the determinants of their health than we have thought. For the past two decades, health promotion around the world has moved away from an original concentration on education and information. Health promotion is now seen as a comprehensive social and political process that not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions, to alleviate their impact on public and individual health. Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health (WHO). Now, as in Snow's time, what you eat is less important than where you live and what you earn. Our equivalent of the cholera map might be one of Colin Mathers' from the Health & Welfare useful tables showing how mortality rates differ between socioeconomic levels. This one shows deaths among young adults. The vertical axis showing deaths per 100,000 people and the horizontal axis showing increasing socio-economic disadvantage.
If this is our equivalent of the cholera map, the part of John Snow might be played today by Michael Marmot. Marmot went to medical school in Sydney in the 1960s. "When I was studying medicine," he said, "I used to walk around the wards in hospital and see all these people with heart disease and chronic bronchitis and liver problems and so on and think, we're putting Band-Aids on these people. There's got to be a better way..." Marmot wanted to find out why people got sick in the first place. Curing individuals wasn't enough. He wanted to cure entire societies. And much the same thoughts occurred to me as a general practitioner working in refugee camps in Eastern Africa and as a GP working in Aboriginal town camps in Alice Springs - somehow we have to find out how we can improve the health of communities, nit just individuals. Marmot has been working for several decades on an enormous study of English public servants - the Whitehall study. In the 1960s, a group of epidemiologists set out to study the heart-attack rate among the civil servants of Whitehall, all white-collar workers, mostly Anglo-Saxon, and all middle class. The scientists began by looking at obvious risk factors for heart disease such as diet, exercise, and smoking. They weighed and measured the civil servants, compared their blood pressure readings and cholesterol levels, and interviewed them about different aspects of their lifestyles, including their exercise, smoking, eating, and drinking habits. Marmot soon found that those in the lowest employment grades were four times more likely to die of a heart attack than others at the top of the hierarchy [and] were also more likely to come down with other afflictions such as strokes and certain cancers and stomach diseases. Perhaps the most surprising finding of the Whitehall study at the time was that everyone in the hierarchy seemed to be vulnerable to the effects of social status, not just those at the bottom. Even a small increment in social status could be reflected in statistics on life and death. For example, "administrators," ... who design policies were half as likely to have a fatal heart attack as the "executives" who carried out the policies. For the clerks, who worked for the executives, the risk of a fatal heart attack was three times as high as it was for administrators. What this tells us is that it is healthier to make policy than to implement it. For the remaining support staff, such as assistant clerks and data processors, the risk was four times as high as for the administrators. All of them seemed to be part of some mortality gradient. If a virus or something toxic in the water were killing as many civil servants as the professional hierarchy itself seemed to be, the Whitehall buildings would be evacuated and closed down. In part, this difference is because people in lower administrative grades and people in lower social groups smoke more and eat worse. If that was the only problem, the remedy would be to step up your work of advising them on what's good for them. However, it's not the only problem, or not the whole problem. Marmot found that class differences in death rates remained even among civil servants without blood pressure or cholesterol problems, and even among nonsmokers and joggers. Less than half of the excess risk of a fatal heart attack in lower-grade civil servants was explained by higher cholesterol, blood pressure, smoking, or other conventional risk factors for heart disease.
Other studies have found similar social patterns of disease. Smoking, diet, and other conventional health risks certainly matter, but social standing seems to matter too, and for some people it matters even more than all the other risks put together. Scientists are now working on finding the cause of this association. It may be that the link is through stress, or stress of the wrong sort, having a biopsychosocial impact, although that's not certain. By this time, of course, my analogy with the Broad Street cholera epidemic is becoming slightly strained. The most obvious difference is that Snow's observations not only told him what the problem was likely to be but also suggested a remedy. Our observations do not. We can't yet work out where the pump handle is. Rank in the workplace is obviously important, but GPs can't prescribe promotions, and even if they could that might not fix the problem. The problems are multifaceted, multicausal, and multiconsequential, and interventions can have unpredictable and incalculable outcomes. GPs, in short, are now facing the same dilemmas that the health promoters have been wrestling with for a decade. I very much appreciate the opportunity to draw on your responses. We don't know whether we should be looking at the general level of inequity in our society, our degree of social cohesion, or the extent to which the world around us seems coherent and understandable. There is suggestive evidence that links health with social support11 and 'social capital'12, where social capital is the cement that holds a community together - the existence of networks and relationships that foster and reward trust, social responsibility, and co-operation. Kawachi and his group checked social capital in each American state, as measured by membership in voluntary groups and level of social trust, and they found that income inequality was strongly correlated with both lack of group membership and lack of social trust. In turn, both social trust and group membership were associated with total mortality, as well as rates of death from coronary heart disease, cancers, and infant mortality. Their tentative conclusion is that income inequality leads to increased mortality via disinvestment in social capital. The GPs network across Australia is itself a key involvement in Australia's social capital, and one of the key purposes of the Divisions program in General Practice was to involve GPs in health promotion at the level of populations rather than individuals. GPs are now moving out of the surgery into the community and working with other groups and organisations on community-based health promotion. The Division's Public Health and Health Promotion SERU has produced a Draft Guide to Community Based Health Promotion that ensures consultation, organisational and interorganisational capacity-building, and sustainability. The Draft recommends projects that use 'multiple strategies such as education, information provision, media, community development approaches, coalition building, advocacy, legislation and economic measures'. This maps out the different levels at which health is determined and in which interventions can operate.
The Division's health promotion policy covers the full spectrum from advice to the individual to lobbying the government, and is a heartening commitment from the field to the aims of health promotion. What, then, is the role of the individual practitioner? Let us take the field of mental health promotion. A WHO study13 suggests that 64% of patients have a psychological problems that require attention. Given that the prevalence of serious mental disorder requiring psychiatric intervention is below 5%, what are GPs to do with the other 59%? Large parts of many of these problems will doubtless be able to be affected by strictly medical solutions - sleeping pills for sleep disorders, tranquilizers for anxiety states. There is plainly scope for GPS to act as health advisers, recommending the responsible drinking or the physical activity that will make the person feel better and enjoy life more. There is the role of counsellor - providing a sympathetic listener and an unbiased commentator. There is the role of social worker, adopting an empowerment approach that tries to identify the patient's main problems, to work out what can be done about them, and to refer him or her to an agency that can help carry the plan out. The really difficult question, however, is how we got to a situation where 64% of patients are classified as having a mental problem. Once the figure gets over 50%, that's not a disease, that's normal. People who don't have any symptoms of mental disorder are deviants. Are we pathologising the normal stresses and strains of life? Is it a good thing that all our social, environmental, and person stresses are eventually reinterpreted as medical complaints? Should we be asking instead what it is about life in the twentieth century that produces these symptoms? Lifesavers can be kept so busy pulling half-drowned people out of the river that they haven't got time to walk along the bank and see who's pushing them all in. Mental illness is a very serious affair. Suicide rates among the young are still rising, and this is an immense tragedy. Suicide is much more common among people with identified mental disorders, which suggests that we need to pay closer attention to the conditions patients present with. It is also true, however, that suicide rates are much higher among rural youth than among youth in the cities - which should turn our attention to the contribution of the environment.
If we ask why rural rates have risen, we come up with possibilities such as that the rural economic downturn, the strain on small rural communities, and a major population exodus from towns with fewer than 4,000 people have meant added health burdens for those communities. (Dudley et al, 1998) If we ask more widely about what differentiates country adolescents from their city peers, we come up with answers such as lack of access to services, higher unemployment and a consequent lack of a sense of being needed and having a place, a general rural feeling of decline, rejection, and alienation, and a shortfall of hope. General practitioners can act in the surgery as doctors, and in the community as citizens, help fight these ills. In health promotion, however, the challenge for the profession is to combine the two roles - to bring to their participation in community advocacy their knowledge of the health consequences of social decisions, without reducing all the issues to medical problems with medical solutions. Speakers later in the morning will be providing examples of the support that's available from the Divisions for such enterprises. The involvement of GPs in the National Mental Health Strategy, for example, and the funding for this, is up for negotiation at the moment. By now GPs are fairly used to working on health education at the Individual level. The projects that the Division is engaging in now extend your influence into such Settings as schools and local government areas. Institutional change, however, is another matter again - very, very difficult to achieve, and enormously influential when you do achieve it. Now we have a guide to Community Based Health Promotion, perhaps our next need is a guide to Advocacy, Legislation and Economic Measures. We need to consider government and social action not simply as another means for bringing pressure on people's bad behaviour, through such regulatory measures as higher cigarette taxes, but also as a means to shape our infrastructure in a manner that supports health. The British government and the British medical associations recently announced a general push towards improving cardiovascular health and reducing pollution, injury and social isolation by discouraging the private car in favour of public transport. This campaign illustrates the wide ambit of health promotion. Should Australian GPs join in a lobbying campaign in this area? Should they agitate to maintain subsidies to country services and facilities, pointing out that closing down a country railway station increases the suicide risk in that area? Even more contentiously, should they support measures to reduce the income gap between the very rich and the very poor? How far can GPs go into the gray area that separates making a case for health from straightout politics? How far can health promotion go? If we are to go along that path, it will certainly be much safer for us all if we take it together. GPs must experiment with testing their established skills in new social arenas.
References
|
|
Copyright © 1999-2001
Reviews of Health Promotion and Education Online, Internet Explorer 5.0 or later version gives the optimal visual effect of this website. |
