Presented with such great opportunity to share my opinion I decided to
contribute a few lines myself. First I would like to thank all the people
who keep the health determinants argument alive.

As I understand the debate the issue is about the priority of either
proximal or distal population health determinants. Hardly anyone can argue
that socio-economic factors are just methodological "noise". In fact they
seem crucial. Investment in population health (considered "an intangible
asset" much like corporate investment in brand recognition is) brings the
highest returns at the distal end of the spectrum. If poverty "causes" other
proximal risk factors it is sound to target the root cause. It does not mean
however that redistribution (though it may be desirable for various reasons)
necessarily increases population health level. Although poverty, social
exclusion etc. are terms defined no less precisely than "brand recognition"
or even GDP (sic!) there is still room for some thought experimentation.

Poor people are in poorer health not because of  the noxious effect of their
low income per se but because of their lifestyle, environment they live in,
state of mind, self-esteem, identity, etc. If smoking is an example of
self-destructive behavior it is futile to convince the poor of its influence
on health. If rationality is related to income and education, the use of
rational arguments makes little sense. What about the mere income disparity?
Studies show that income disparity increases disease risks. Apparently
self-esteem and sense of coherence come into play. Theoretically, it would
therefore be possible to improve health of the underprivileged without
redistribution. It would take much social marketing to convince them that
little consumption and much free time as well social and cultural values are
more desired than earning, spending and permanent dissatisfaction. Yet that
very dissatisfaction is the driving force of our economic model. Marketing
creates "motivational tension" by creating needs. Such tension makes people
accept low paying jobs to pay off debts. Poor children want to have
expensive sports shoes and video games and eat fashionable foods, they will
not be able to afford healthy living or even consider it due to cultural
framework. Products targeted to the poor sell security, identity,
friendship, love, sex etc. for their basic needs could be much easier
satisfied. Few people know how cheap and easy it is to build a housing
complex using primitive materials such as clay and straw. Nowadays some
yuppies rediscover forgotten technologies turned trendy. Small backyard
gardens could provide sufficient amount of fruits and vegetables as well as
exercise while contributing to social capital. The real question is one
about the nature of progress. Should we make a bigger pie and redistribute
or shall we be more concerned about the ingredients and additives in that
pie. In China the pie got bigger as well as the problem of chronic diseases.
Poorer people in the countryside are still much healthier, without modern
medical technologies.

I'm by no means taking the "anti-progressist" stance but to make an
objective scientific argument (assuming such is possible) we must see beyond
the established paradigm. I'm also far from calling for system change but it
must be understood that market mechanisms, as applied in modern world,
contradict population health. The question is: Cui bono? Who stands to
benefit from health improvement?

In my Ph.D. dissertation I conclude that long-term investment in population
health is nobody's priority. Interestingly, there might be a critical
population health level below which economic growth could be negatively
affected and that always calls for action. Infectious disease epidemics are
a good example, also heart disease in middle-age workers. A couple of years
ago ADL issued a report on the "benefits" of smoking. This habit not only is
a source of taxes but also is saving a lot of taxpayers' money in social
spending. Health expenditure on smoking victims is relatively small compared
to savings stemming form early deaths shortly after retirement. Even the
communist governments knew it and did little to effectively reduce smoking
rate. Now with a global shift toward ceding responsibility for health
towards individuals paralleling chronic disease epidemics there is less and
less rationale to target risk factors.

Disease is a source of economic growth and provides employment to about 10%
of labor force. Keeping in mind health determinants we know that improvement
in population health would require less stress, more social interactions,
moving to cleaner environment, switching from cars to bicycles, more time
for sports; also health requires mental and spiritual development. That
would mean recession and perhaps an economic disaster. If people invested in
social, educational and health capital rather than in stocks and bonds the
stock market would collapse. And how could such capitals be taxed?! People
should be healthier but without exaggeration. Too healthy is not desirable.
Also too much knowledge (wisdom) is rejected by the market and even
threatens it and too much social capital hampers the market economy (stated
in one of the OECD papers). A CEO of an insurance company told me once that
people should not be too healthy or else they will become less inclined to
purchase health insurance.

Therefore health promotion is desirable but it should not be overly
effective. It should only target the tip of the iceberg and the economy will
grow while its beneficiaries maintain satisfactorily good health. It
resembles environment protection: we should "clean up the world" without
asking where the litter is coming from. Therefore there is more money in
palliation than in true prevention. I repeat, I don't see how this should be
changed.

Finally, in the debate a tacit assumption is made that people desire health.
Empirical studies show that health has low priority and consumption takes
precedence when actual behavior (revealed preference) is analyzed. Even so
people declare that health is the most desired good. Such declarations don't
seem to be rational and also result from imperfect information as to the
risk factors. People still believe that modern medicine is highly effective
and efficient.

There in no effective mechanism to invest long-term in general population
health and investing in health of the underprivileged merits even less
attention, as long as they don't vote consciously. And conscious voters
usually demand more spending on medical technologies, despite the fact that
they mostly benefit the more affluent and are increasingly ineffective at
the margin. Paradoxically, they should demand that modern medical technology
be financed privately, while public funds be diverted for prevention. In
reality medicine is becoming private while prevention disappears from the
agenda. People support technologies because they believe they would increase
life span. In fact most of the increase has been due to saving the neonates,
the burden of chronic diseases increasing, particularly among the poor.

In my dissertation I propose two theoretical solution, for as I mentioned
practical solutions seem impossible due to the lack of stakeholders acting
for health. First solution is to create an obligatory prevention fund which
means targeting risk factors most efficiently. The fund should be financed
according to the maxim "those who harm should pay", much like "polluters
should pay" in environment. Naturally, that leaves much room for politics.
The other solution utilizes the very market mechanisms: it securitizes the
risk of population health, risk to the entity responsible for financing
health. This concept is based on idea of internalization of health
exteriorities. Health financing authority might issue "cat-bonds"
(catastrophic) the future value of which would depend on health status
indicators and spending levels. That could be a way to control spending on
treatment and promote long-term investment at the level of distal risk
factors.

Using this opportunity I would like to establish contacts with researchers
in the field in Canada for possible collaboration. I will be moving to
Canada in a couple of years.

Jaroslaw G. Wechowski, M.D.
[log in to unmask]
Warsaw School of Economics
College of Management and Finance
Ph.D. candidate (management)

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