Article published in the Island. 23 March 2007


-Your health is decided by politicians! 
 
by Dr Saroj Jayasinghe


The lay public is bombarded with information on what
to eat, when to sleep, how to exercise and methods of
relaxation. The media is adding fuel to this with
slogans relating to health: "healthy life styles",
"prevent non-communicable diseases" and an abundance
of articles by experts who describe diseases and
complicated procedures or heroic operations. This
article is provocative. It attempts to convince the
reader that a population’s health is more often than
not determined by social and political factors, rather
than doctors, pharmaceuticals and hospitals. In order
to develop the argument, it is necessary to define and
understand a few relevant concepts. 

A few concepts

Health is not the mere absence of illness or disease.
It is a state of positive well-being. One can feel
healthy even with a debility such as an amputated
limb. Health also encompasses several dimensions. The
World Health Organisation describes four dimensions:
physical, psychological, social and spiritual. This
means, even with a ‘fit’ physical body, one can be
psychologically unhealthy. 

What does this broader definition mean in practical
terms? Let us reflect on our own experiences for a
moment. Consider the life span from birth to death.
For a greater part of an average life-span (which is
almost 70 years in Sri Lanka), one remains healthy.
Sickness is often limited to a few short periods,
until a serious sickness ends the innings! Look around
and at a given moment, a majority of people around
feel healthy and well. Even the few who unfortunately
become ill with a chronic illness, have led a healthy
life for a greater part of their lives, before falling
sick. 

The long-term goal of society should be to maintain
and improve the health of the population, and to
prevent persons from prematurely dying or going down
with illness. Caring for those who are sick is
essential, but the overall emphasis of society’s goal
should be to find ways and means of maintaining health
and promoting health of the whole population. Thus one
should not confuse the subtle difference between the
main focus of the current health services (i.e.
‘caring for the sick’) with that of society’s main
goal (i.e. maintain and promote population health).
Once the goals of society are clear we need to pose
the next obvious question "Who contributes most to
maintain and promote our health? What contributions do
the health services make towards maintaining and
promoting health?"

Who is responsible for health of the population? 

Health services play a crucial role in caring and
curing for those who have unfortunately fallen ill.
However, maintaining health and health promotion are
less reliant on the health services and are dependent
on ‘other sectors’. Therefore if one adds up the
totality of health of a population the key
determinants are beyond ‘hospitals and doctors’.
Population health is determined to a greater extent by
society working through other sectors, more than
through health services. The next few paragraphs
describe what these ‘other’ sectors are and the link
to politicians. 

Other sectors which contribute to health 

A few examples are education, employment conditions,
housing, and economic status. (I have deliberately
left out well known sectors such as provision of clean
water, sanitation, air pollution etc.) 

Education is a key determinant of health of a
population. Those with high quality education (e.g.
university education) have a larger proportion of
healthy persons, than the uneducated. The poorly
educated die younger and are more often affected by
illness. 

Employment conditions are also important for health.
Being employed in a secure job is good for health.
Unemployment (even threat of unemployment), manual
work, night shifts, and lack of a supportive work
environment contribute to people falling physically
sick, absenteeism and low productivity. 

Housing has a complex influence on health. In general
terms, good housing leads to improved health. Research
in Sri Lanka carried out by the Malaria Research Unit
of the University of Colombo had shown that poor
housing is linked to higher rates of malaria. More
recently, the British Medical Journal of 3 March 2007
describes a study where mere provision of good
insulated housing improved the health of the
population . 

Economic status is a key determinant. Economic
development (with equity) promotes health. On average,
the richer survive longer than the poor. The richer
groups suffer less from communicable and non
communicable disease such as diabetes, stroke and
heart attacks. (It is a myth that these diseases are
confined to the affluent). Scientists use the term
‘social determinants of health’ to describe all these
‘other sectors’ which impact on health. 

These social determinants are largely a result of
political decisions. Lack of housing (e.g. 50% of
Colombo city population live in unsuitable houses
(i.e. ‘slums’), poor quality education in the country
(e.g. 18% sixth graders cannot write as highlighted in
the Island editorial of 21 March 2007) , the status of
labour laws (e.g. increasing pressure from
multi-nationals to restrict labour rights) are finally
based on political decisions. Doctors and hospitals
deal mostly with the final detrimental effects of
these decisions. Health is a wider issues not limited
to the Ministry of Health. It is the responsibility of
all the ministries of government and a cross-cutting
issue, with political overtones. One pays a price if
this reality is not appreciated, and often the price
is in human lives. 

The politics of health and specific disease prevention

What are the implications of knowledge on social
determinants of health for disease prevention? This
topic is of interest because the health services have
several programmes aimed at disease prevention and
health promotion. The specific simple example is used
because currently there is a lot of in Sri Lanka to
prevent an ‘epidemic’ of non-communicable diseases
(NCDs, such as diabetes, coronary heart disease,
hypertension, stroke). 

The following facts must be mentioned. Firstly it is
well known that the diet taken by the population is an
important determinant of the prevalence of these NCDs.
Secondly, marketing campaigns by the food industry
leads to unhealthy dietary habits among children, a
consequence of which is childhood obesity. These obese
children are at a higher risk of developing diabetes,
heart disease and a many other chronic diseases in
later adult life. One needs to view the numerous TV
channels in Sri Lanka for a few hours (especially the
children’s programmes) to observe how ‘unhealthy’ fast
foods are being aggressively marketing to children.
This includes sausages, ice creams, sweetened drinks,
biscuits, sweets etc. If Sri Lanka is to take
comprehensive action to curb an epidemic of NCDs it
also needs to discourage unhealthy food habits in the
population. Should the government take any action to
curb such marketing methods (*see foot note) or
restrict the opening of fast-food outlets? 

Any action on part of the government will be based on
political pressures and realities. One common
political decision in such circumstances is to be
deliberately indecisive (i.e. not to take any action
on promotion of fast-foods aimed at children). If this
happens, victory for the fast-food industry is almost
assured. The dull faces of the well meaning health
professionals on TV attempting to educate the public
on healthy life styles and the detrimental effects of
fast foods is no match to the smart sportsmen or
cartoon characters who promote the fast-foods! Thus
extending this argument further means that the public
have to bring on pressure at the political level to
implement ‘pro-healthy’ policies. Failing to
appreciate this fact may condemn the next generation
of children to premature death and illness. 

Conclusion

The article challenges the commonly held views on the
definition of health and the belief that population
health is largely determined by the health services.
Instead we propose a broader view of health with the
hope that once these concepts are understood, the
public and the health profession will direct more
attention to policies which promote health, rather
than be limited to curative services and hospitals. In
order to be effective most such policies require
action in the political arena. 

(*Foot note: A similar debate is underway in the US,
and there is an interesting article on food marketing
and childhood obesity in the prestigious medical
journal ‘New England Journal of Medicine’ 15 June
2006. It can be accessed freely from
http://content.nejm.org/cgi/content/full/354/24/2527
).


The writer is Professor, Department of Clinical
Medicine, Faculty of Medicine, University of Colombo,
Sri Lanka & Consultant Physician, The author can be
contacted using the following e-mail address:
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