International Journal of Epidemiology 2002;31:523-526
© International Epidemiological Association 2002
Editorial |
The accidental epidemiologist: losing the way or following social-epidemiological leads?
Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK. E-mail: mary.shaw{at}bristol.ac.uk
As academics we focus very much on epidemiological matters discussed in the forum of a fairly narrow range of published literature, yet the real stuff of epidemiology (and its contribution to public health medicine) is constantly taking place in the wider world around us. This editorial was written at the beginning of the calendar year, a time when, once again, magazines, newspapers and television overflow with advice for improving health and well-being. Each January we are repeatedly bombarded with messages to quit smoking, lose weight and do more exercise. ‘Start the new year right—treat your body to a tune-up!’ Indeed, health and well-being ‘tips’ are now a perennial feature of an approach to health which in the West has become overwhelmingly individualistic, and increasingly consumerist—health (and health care) is something that the individual purchases.
Of course, if ‘the public’ did follow this advice the impact on public health, not to say the public purse, would be huge. Imagine the effect if smokers really did kick the habit. In reality behaviour change is very difficult to achieve—the evidence of the effectiveness of even the best-crafted mass media campaigns aimed at reducing smoking, for example, is not strong.1 Similar difficulties are faced when exercise is the issue. The promotion of physical activity has been argued to be the best option for public health, at least in terms of coronary heart disease.2 In England, the majority of people are not physically active;3 the World Health Organization (WHO) estimates that 60% of the world's population is not physically active enough to gain health benefits.4 Systematic reviews5,6 have found that public health interventions to increase levels of physical activity often have no overall effect. At best they result in increased levels of activity in only a small proportion of the population that are for the most part only maintained in the short-term. In the mid-1980s WHO identified ‘settings’ (workplaces, neighbourhoods, schools, etc.) as vehicles for health promotion, yet this signalled only a minor shift away from individualistic strategies. The majority of interventions to improve and promote population health continue to focus on individual behaviour change. Even when we know the effect is minimal, we still cling to the individualistic model.
Such findings, and failures, surely ought to encourage us to think outside the box, to look beyond the individual. Most epidemiological studies contain clues, if not evidence, of the effect of broader-level factors impacting on health where interventions could be aimed. Yet changing the errant behaviour of individuals remains a favourite with even those who are the most well-informed and well-placed to bring about other forms of change. In 1999 for example, the Chief Medical Officer for England issued advice on his ‘top ten tips for better health’ (Figure 1
). Despite a raft of reports and policies (www.doh.gov.uk/healthinequalities) which acknowledge the role of socioeconomic and structural factors in producing health inequalities, these tips were released without reference to such broader issues. Responsibility was thus placed firmly upon the individual. The Townsend Centre for International Poverty Research at the University of Bristol responded to these tips with an albeit tongue-in-cheek list of alternatives which (re)place the emphasis and responsibility for change firmly beyond the individual, instead focusing on structural-level issues such as the distribution of income, the provision of welfare benefits and housing conditions.
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The cost of this unstinting focus at the micro-level of the individual is that other approaches are given short shrift—the modification of factors beyond the individual is an option less commonly considered. Intermediate-level interventions, such as those focused on schools, workplaces or in communities (for example, changing the range and quality of food available in a workplace canteen, providing pedestrian crossings near busy roads, supplying free condoms in places where unsafe sex is likely to occur) are less common. Many settings-based interventions are in effect individual-based approaches in another guise, using a particular setting to deliver messages on individual behaviour change—sex education in schools being a prime example. Even rarer than these intermediate-level interventions are macro-scale legislative approaches to public health—most legislation concerning health relates to the regulation of employment or the financing of health care. To find examples of legislation for the explicit purposes of improving public health we have to look to history (many other instances of public health lessons can be learnt from retrospection).8 A classic example of a legislative change in Britain was the Clean Air Act of 1956, which limited the siting of polluting emissions; the ‘pea souper’ of 1952 (a mixture of fog, smoke and sulphur dioxide) is said to have killed over 4000 people.9 Figure 2
evocatively depicts not only the polluted air which blighted the environment in the early 1950s, and which the individual living in such areas had no choice but to inhale, but also indicates that this was at the time considered to be a very public health issue.
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More recently legislation bringing about the detoxification of domestic gas in Britain was estimated to have saved 6700 lives10 and restrictions to the pack-size of paracetamol and salicylate is also said to have reduced the number of deaths from deliberate self-poisoning.11 Somewhat more controversially, seat belt legislation is credited by many with saving thousands of lives and avoiding countless serious injuries in a number of countries. The controversy derives from the ‘risk compensation’ critique12 claiming that the greater feeling of safety provided by seat belts (or other such interventions) leads to displaced/ alternative risk-tasking—you feel safer and so you drive faster. Though much proclaimed this theory has been disputed by empirical evidence;13 moreover, risk compensation becomes irrelevant when environmental change is the issue—as stated above, we cannot make lifestyle choices about the air we breathe. On the issue of the health benefits furnished by seat belts (and also by the use of condoms) Richens and colleagues14 state: ‘there is an abundance of evidence of benefit to individuals directly exposed to risk. When evidence of benefits is sought at population level it becomes much harder to show beneficial effects.’ It seems ironic that we continue to pursue individual-level interventions which have been shown to be of very limited effectiveness, but we rarely entertain the pursuance of macro-level strategies that have the potential for improving the health of individuals, but then we have long been guilty of short-sightedness when it comes to choosing appropriate forms of evidence.15
Clearly there are some areas where a structural approach to public health has potential, or is at least less problematic than other options—regulating the industrial output of factories is certainly an easier target than tackling the mighty power of the tobacco companies, or restricting the smokers' freedom to choose to smoke. Accidents and injuries, a theme in this issue of the International Journal of Epidemiology, is one such area where structural and legislative approaches might have most promise. ‘Accidents’ are not randomly distributed events, in either lay or statistical terms. Instead they are patterned by social, cultural and environmental factors—they even reflect the way we organize time, varying by day of the week and time of day (the patterning of road traffic accidents among children reflecting school timetables are a prime example of this16). Accidents are what Durkheim would term ‘social facts’,17 existing sui generis over and above individuals and being the product of the way that society and the environment are organized (you cannot die in a road traffic accident unless you live in a society with cars and roads; you cannot shoot yourself or someone else if you do not have a gun). Half a century after Morris18 highlighted the relationship between the rate of accidents in coal mines with the number of workers in a mine as a ‘social-epidemiological lead’ (the greater degree of camaraderie in smaller mines protecting the workers in the event of danger) a British Medical Journal editorial called for the banning of the word ‘accident’.19 In that editorial Davis and Pless argue that the word ‘accident’ is inappropriate for events that are both predictable and preventable.
A prime example of such predictable and preventable events, and of the public health potential of a legislative change, is the current situation with firearms in the US. In 1994 in the US there were 38 505 firearm-related deaths—over 17 800 firearm-related homicides, over 18 700 firearm-related suicides and over 1300 unintentional deaths due to firearms (‘accidents’ if you prefer the more familiar, less attributive, vocabulary).20 In 2001 the Surgeon General in the US released a report on Youth Violence,21 which is seen as an ‘epidemic’ deserving of high priority intervention, prompted at least in part by recent school shootings. The report lists 27 specific youth violence intervention programmes, including ‘functional family therapy’, ‘multisystemic therapy’ and ‘life skills training’. The report notes that gun buy-back schemes, firearm training and mandatory gun ownership (approaches which were expected to deter gun violence by increasing the number of private citizens who were trained to use guns properly and who owned firearms for protection) have been found to be ineffective in reducing firearm-related crimes. There is no mention of simply restricting the availability of firearms through legislation. Follow this social-epidemiological lead: the rate of homicides due to guns is 175 times higher in the US than in Britain; 48% of Americans compared to 4.7% of British households have guns.22 Gun control has been found to be an effective intervention for reducing both homicide and suicide rates.23,24 Yet in the US, where every individual has the right to bear arms but not everyone has the right to health care, a legislative approach to this problem is clearly seen as so politically objectionable that it is not even raised as a possibility.
As professionals concerned with public health, how often do we reflect upon the bigger picture, let alone do anything about it? All too often we forget that behaviours and decisions at a number of levels—from the individual, to the organizational to the political—affect the health of populations. Are we losing our way, missing social-epidemiological leads, and foregoing opportunities by not considering the role of the legislature in improving public health?
References
1 Sowden AJ, Arblaster L. Mass media interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews 2000; 2:CD001006.
2 Morris JN. Exercise in the prevention of coronary heart disease: today's best buy in public health. Med Sci Sports Exerc 1994;26:807–14.
3 Department of Health Physical Activity Task Force. More People, More Active, More Often. Physical Activity in England. London: The Stationery Office, 1995.
4 World Health Organization. Physical Activity Factsheet. 2002. http://www.who.int/hpr/physactiv/physactivfactsheet.pdf
5 Riddoch CJ, Puig-Ribera A, Cooper A. The Effectiveness of Physical Activity Promotion Schemes in Primary Care: A Systematic Review. London: Health Education Authority, 1998.
6
Lawlor DA, Hanratty B. The effect of physical activity advice given in routine primary care consultations: a systematic review. J Public Health Med 2001;23:219–26.
7 Shaw M. Try out alternative slant on the ‘Top 10 tips for better health’. Health Service Journal, 27 September 2001.
8 Davey Smith G, Dorling D, Shaw M. Poverty, Inequality and Health in Britain: 1800–2000—A Reader. Bristol: The Policy Press, 2001.
9 Brimblecombe P. The Big Smoke. Methuen: London, 1987.
10 Office of Health Economics. Suicide and Deliberate Self-harm. London: Office of Health Economics, 1981.
11
Hawton K, Townsend E, Deeks J et al. Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study. BMJ 2001;322:1–7.
12 Adams J. Risk. London: University College London Press, 1995.
13
Robertson LS. Reducing death on the road: the effects of minimum safety standards, publicized crash tests, seat belts, and alcohol. Am J Public Health 1996;86:31–34.
14 Richens J, Imrie J, Copas A. Condoms and seat belts: the parallels and the lessons. Lancet 2000;355:400–03.[CrossRef][ISI][Medline]
15
Davey Smith G, Ebrahim, S, Frankel S. How policy informs the evidence. BMJ 2001;322:184–85.
16 Department of Transport. Children and Roads: A Safer Way. London: Her Majesty's Stationery Office, 1990.
17 Durkheim E. Suicide: A Study in Sociology. London: Routledge, 1999 (first published 1897).
18 Morris JN. Uses of Epidemiology. Edinburgh and London: E&S Livingstone Ltd, 1957.
19
Davis RM, Pless B. BMJ bans ‘accidents‘: Accidents are not unpredictable. BMJ 2001;322:1320–21.
20 National Center for Injury Prevention and Control. National Summary of Injury Mortality Data, 1987–1994. Atlanta, GA: Centers for Disease Control and Prevention, November 1996.
21 Department of Health and Human Services. Youth Violence: A Report of the Surgeon General. Washington DC: Department of Health and Human Services, 2001.
22
Chapman S. Elimination of firearms. BMJ 1997;315:1019–20.
23 Killias M. Gun ownership, suicide and homicide: an international perspective. In: del Frate A, Zvekic U, van Dijk JJM (eds). Understanding Crime and Experiences of Crime and Crime Control. United Nations Interregional Crime and Justice Research Institute, Publication No. 49. Rome: UNICRI, 1993.
24 Lambert MY, Silva PS. An update on the impact of gun control legislation on suicide. Psychiatr Q 1998;69:127–34.[Medline]
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