What will the person in the street make of recent public health scare tactics?
As the politics of austerity continues to bite into NHS and other public budgets, Britain’s top health promotion brains have decided that precious future health resources can be saved by ratcheting up project fear. Having pretty much thrown in the towel on improving the nation’s wellbeing through collective, political and infrastructural efforts, the high-ups of Public Health have opted to concentrate even harder on peddling the idea that health is an individually determined phenomenon.
The latest twin onslaughts to hit the mass media this summer are the “there is no safe level of alcohol consumption” furore and the “how old is your heart?” campaign. Both are firmly rooted in the traditional probabilistic public health illusion that individual life paths can be predicted from population-level epidemiology. Both espouse the cruel half-truth that everyone’s health is in their own hands. And both firmly place life quantity (years lived) high above life quality (how much you enjoy it). In fact, the concept of wellbeing as both a social and individual value is notably absent.
The anti-drinking push and the ‘heart age’ campaign come from different stables and they both attempt to communicate risk differently, however, they do have a common intellectual foundation. In a nutshell, it says: – Forget about economic inequality, forget about noxious air, forget about hate and discrimination, forget about agricultural and industrial poisons, forget about interpersonal violence, forget about inadequate housing, forget about individual and collective misery and forget emotional wellbeing. It’s official (again). It’s all about booze, chips and cake. And it’s all about how many years you live – to hell with quality, let’s concentrate on quantity.
The first question that many people will raise about the call to abstention from alcohol is: Why? On what precise ethical grounds should anyone propagandise me into enjoying my life less, simply so I can have more of it? Frankly, it doesn’t sound up my street at all, if it’s all the same to you.
The second question about the drinking advice may well be about ‘picking and choosing’. How come so much effort goes into some “health risks” and not others? As no less a risk expert than Professor Spiegelhalter of Cambridge University commented: “There is no safe level of driving, but government do not recommend that people avoid driving”. For “driving”, you could actually substitute quite a few normal daily activities and exposures. There’s no safe level of crossing roads. There’s no safe level of breathing urban air. There’s no safe level of ___________ (fill space with your favourite mundane activity).
The third question about the alcohol consumption thing might be – “Really?? – how come I know so many people who drink (some of them quite a lot!) and it hasn’t made them ill?” And while epidemiologists and health promotion people will have many counter-arguments (hidden liver damage, cancers you don’t know about that are caused by drink etc), they won’t be able to win THE argument. Because their approach is based on an uncomplicated probabilistic mapping of statistics derived from huge aggregate populations directly onto each of our individual lives. And you don’t need a string of University degrees to know that “it doesn’t actually work like that, mate”. The links between lifestyle, behaviour and health outcome are way more vexatious than that. And ordinary people know this from their own observation and from information shared. A direct link between (any!) alcohol drinking and the occurrence of ill health and death is disproved on a daily basis in the lives of almost everyone in societies where drinking is culturally embedded. We all know people who “shouldn’t” survive the lifestyle they lead. And we all know people who succumb, even though they have lived “healthily”. Against this backdrop, the “no safe level” mantra becomes nothing more than a barroom laughing stock.
The “heart age” campaign is, in many ways more interesting. While some of the issues raised about the heart age calculator will be the same as those asked about alcohol abstention, others will be different. And they will flow from the fact that the heart age calculator represents a recent (in the last five years or so) change in the way that heart attack and stroke statistics are used by lifestyle campaigners.
For several decades the standard method that a doctor, nurse or health promoter used to scare a patient into lifestyle change was to talk about percentage risk. More technically, this is a percentage risk over a specific period. For example, “if you continue with your current approach to food, drink, exercise and body shape you have an X% chance of having a heart attack or stroke in the next 10 years, but you can reduce that risk percentage by changing Y in your life”.
The “heart age” calculator approach, on the other hand, tells the individual that, even though they are aged, say 50, their heart is effectively older than they are and has the age of 58. This is because the fifteen or so questions they have answered about themselves, their cholesterol, their blood pressure and their lifestyle have revealed that they fall into a particular percentile of a population distribution.
The heart age ‘statistic’ goes along with another number, which is the age to which the person can expect to live without a major cardiovascular event. So the 50-year-old in our example will find out that they can expect to reach, say, 74 without keeling over. On top of this, the software can of course simply do some of the calculations in reverse, so our hapless 50-year-old finds out that the 74-year figure could be pushed to 78 if they reduced their body-mass index and lowered their cholesterol (or whatever).
One (unintended?) consequence of this is that the punter can now make an informed decision and say “Thanks, I think I’ll go on with the smoking and trade that off against the years you said I could gain. To be honest I’d rather have the fewer years plus the ciggies than the longer life without.” I don’t suppose you’re meant to use it like that – but those ordinary people out there can be very canny sometimes!
As you might imagine in this day and age, the health promotion people are basing their change in risk communication on research evidence. And as you might imagine, it’s not hard to find conflicting evidence in the publication record. If you’re into this kind of thing, the evidence for using ‘heart age’ as a propaganda tool is mainly from a publication by a team from the Balearic Islands. Sceptics and traditionalists will find themselves more persuaded by the evidence produced by Australian researchers. As so often with expensively produced research evidence, ‘you pays yer money and yer makes yer choice’.
One piece of evidence that the calculator people forgot to collect was information on what effect publication of the heart age ‘tool’ might have on demand for General Practice health checks and consultations. And it appears that this might be quite large and quite unwelcome, especially as a demand surge is quite likely to involve large numbers of our old friends “the worried well”. Ah well – look on the bright side, at least it’ll be another opportunity to try and stuff them with statins. And if that doesn’t work, you could always just go to the pub and drown your sorrows… oh… no… hang on a minute…