Following the World Health Organisation/UNICEF Global Conference on Primary Health Care, Dr Luke Allen, from Oxford’s Department of Primary Care Health Sciences explains how to improve population health
I write from Astana – capital city of Kazakhstan. Hundreds of health ministers, policymakers, academics, and campaigners have braved the cold to reaffirm their commitment to a 40-year-old WHO/UNICEF declaration. The Declaration of Alma-Ata was forged in the geopolitical turmoil of the late 70s and committed countries to social, political, economic and health sector reform, propelled by a sense of democratic social justice.
Today health inequalities continue to widen and the richest in our societies enjoy much longer and healthier lives than the most disadvantaged. Why?
We often tend to think that the main ingredient for better health is access to high quality healthcare: doctors, nurses, hospital beds and fancy scanners. In reality, healthcare is only responsible for around 10% of the health improvements we have experienced over the past 50 years or so. Genetics play a role, but much more important are non-medical factors like education, clean water, transport, the local food environment, access to green space, pollution, and cultural factors that influence the likelihood that locals smoke, drink harmfully, exercise, and eat healthily.
This ensemble of ‘social determinants of health’ are responsible for approximately 80% of deaths due to cardiovascular disease, chronic respiratory disease, type 2 diabetes, and cancers – earning this tetrad the moniker ‘socially transmitted diseases’. It stands to reason that however promising the next precision medicine blockchain nano-delivery VR widget is, interventions that do not fundamentally address socio-political building blocks of towns and neighbourhoods will only ever tinker at the fringes.
That’s not to say that medical tech can’t make big differences to individuals, it’s just that new tech breakthroughs often take a long time to reach the scale where they influence population means, and even then benefits are disproportionately enjoyed by the wealthy. Conversely, interventions aimed at socioeconomic conditions, e.g. welfare, smoke-free spaces, free school meals, fluoridising water or reducing salt in bread, often make a negligible difference to individuals but lead to large aggregate reductions in death and disability with the least advantaged benefitting the most.
The Alma-Ata Declaraton (and the new Astana Declaration) commit governments to the basic, slightly boring work of reorienting their health systems to focus investment on public health measures, communities, and the economic and political environment. This is potentially inflammatory for countries pursuing radical capitalist policies, and for autocracies that struggle with viewing individuals and communities as partners rather than potential threats to stability. Alma-Ata’s audacious vision for health systems also challenges the British health research paradigm, reminding us that even the biggest pharma RCTs are never going to make that much of a difference. We need more interdisciplinary research combining health, politics, economics, and social science, as well as better methods to understand which interventions are most effective in the messy, confounded, complex, and dynamic systems of public life.
Dr Luke Allen (@drlukeallen) is a GP academic clinical fellow working at the Nuffield Department of Primary Health Care Sciences in the Interdisciplinary Research in Health Sciences group. He is also a primary care consultant for the World Health Organisation.