Upstream thinking is a key concept within
health promotion; in our teaching we describe it as a ‘threshold concept’, one that
opens the door to further understanding of the social determinants of health
and of the need for timely preventative action. Why people in powerful
positions don’t seem to ‘get’ this is puzzling.
That problems accumulate so that they
create huge downstream problems has never been better exemplified than recently
with the terrible flooding in southern England and Wales, showing a literal
lack of upstream thinking. It’s now clear that cuts to flood defence spending
is a key cause of the flooding. About £100 million has been cut from the flood
defence budget each year since the Coalition government took power. The
Somerset Levels, which has experienced some of the worst flooding, has had a
£2.2 million scheme cut, which would have improved management on the River
Parrett, the main river draining the Levels. The scheme has been postponed
until at least 2020. Another scheme, further down the same river, costing £6.2
million has also been postponed, even though there was serious flooding there
in 2012. In 2010 the Environment Agency said these defences “urgently need
updating”. The Pitt Review which looked at the terrible floods of 2007 made a
number of recommendations which led the Labour Government to increase spending.
It was becoming clear that extreme weather events caused by global warming was
likely to increase flood events, and together with more houses being in flood
prone areas, there was a clear case for more upstream thinking. Why then didn’t
the coalition government carry on with these flood defences and other obvious
and well tried methods such as dredging rivers? Chris Smith, chair of the EA
has been put in a difficult position, defending his agency’s response yet also
making the public aware that his budgets have been cut and his hands have been
tied.
It’s not as if there isn’t scientific
evidence around – at the end of 2013, before the floods arrived, a paper in the
journal Soil Use and Management warned that there was a problem with water
run-off in the south west, including the Somerset Levels. Because of changes in
the way land is cultivated, there’s been an increase in run-off rather than
water being soaked up, making flooding more likely. Ironically, some of these
changes were designed to alleviate climate change, as maize is being favoured
as biofuel - as well as to feed animals, which is not so environmentally
favourable – and the point about maize
is that firstly it leaves the soil bare during the rainiest months and secondly
it means the soil stays bare before and after harvesting. This means the
stubble and weeds that bind the soil in other crop-growing isn’t there. It’s
well known that maize growing leads to more erosion and is discouraged in
high-erosion risk areas. However, the Coalition government decided to exempt
maize growing from soil conservation measures. Why – when this is a known
aspect within global farming?
Of course, the amount of rain that fell was
unprecedented, though anyone concerned with climate change knew that these
amounts are not a complete surprise. Lord Krebs , the expert advising the
government on climate change has gone on record recently as saying that the
government’s current ‘firefighting ‘ approach will be the only one available
unless more funding is made available. Some
have said that it was only when the flooding came closer to London, with over
184 miles of the Thames flooding that government swung into action and Cameron
was seen touring in his wellington boots. The costs to the economy, business,
insurance companies, let alone the human and emotional toll seem ludicrous.
In the health promotion world, these
failures to think upstream are well known and the latest debacle only adds to
existing frustrations. There seem to have been a mass of headlines recently
that have shown the failure to take timely and preventative action, leaving us
only able to sigh ‘surprise, surprise’. One such headline is “Benefit cuts
explicitly linked to mental health problems” (Guardian 26 Feb 2014 p38). The
headline related to a story about Oxford MIND being awarded a grant of £366,078
from the Big Lottery to cope with the increased number of people experiencing
mental health problems due to the stress of financial insecurity and also due
to being wrongly assessed by Atos, the firm contracted to carry out
fit-for-work assessments.
A tiny part of the NHS budget goes on
preventing illness occurring downstream. 70% of the NHS budget goes on long
term conditions; 15.4 million people in the UK have a ‘long term condition’ and
although the UK has a good record in looking after people with such conditions,
wouldn’t it have been better to have done more to prevent them in the first
place? By 2020 there’s a predicted £30 billion gap between the NHS budget and
what will be needed to care for these roughly 15 million people. A third of people
over the age of 65 admitted to hospital are malnourished, many undernourished;
the cost of caring for malnourished people is double that of well nourished
people due to longer recovery times. Why are so many elderly people
malnourished in the first place?
Although Prof Chris Ham, the well known
expert on health and social policy says that “there is an urgent need to transform
how GPs treat people with these conditions”, this is still a downstream action.
And even this downstream approach is under threat - the BMA has asserted recently that about
100 rural GPs surgeries could close due to government cuts; Dr. Chaand Nagpaul,
chair of the BMA’s GP committee says that “The government has seriously
misjudged the potential impact of its funding changes, especially on rural GP
services”.
A further warning about the ability of
health care to cope in the future came recently from the WHO in its World
Cancer Report, which predicts a ‘soaring’ of cancers related to ‘lifestyle’
habits such as drinking alcohol or consuming sugar. The director of the International
Agency for Research on Cancer, Dr. Christopher Wild, who was one of the
authors, has said, “ Despite exciting advances, the report shows that we cannot
treat our way out of the cancer problem. More commitment to prevention and
early detection is desperately needed in order to complement improved treatments
and address the alarming rise in the cancer burden globally.” I’m reminded of some work that I was involved
in in the mid-2000s, looking at primary prevention of breast cancer, a disease
that has ‘soared’ and which is purely seen as a ‘lifestyle’ disease despite the
fact many women who get it do not have any of the risk factors. The work was
dismissed by ‘official’ government scientists and we learnt that many
scientists who wanted to raise wider issues such as pollution, endocrine
disrupters, chemicals in food and so on, were sidelined or ridiculed.
(References below). There must be a
radical rethink on cancer prevention and one which does not penalize people for
their ‘lifestyle choices’.
In terms of tackling the other major
killer, heart disease, NICE has recently recommended that statins are given to millions
more than the 7 million people currently on these drugs in the UK. The
pharmaceutical industry is keen to develop its preventative agenda and to think
upstream, and although this could be welcome in some ways, there’s clearly a
need too, to be critical of the motives and of the research. As John Abramson,
a senior lecturer at Harvard noted recently, drug companies have not released
the full data on the side effects and efficacy of statins whilst other critics
have said that if GPs know there’s a pill to hand out, they are less likely to
focus on the root causes of heart disease or strokes.
Dementia is a further cause of concern that
is often mentioned in the media and is regarded as something that will stretch
the health service (or as I prefer to call it, the sickness service). Dementia
is on a rapid rise worldwide. With 44 million currently affected, it’s due to
rise to 76 million by 2030. A study at the University of Pittsburgh reports
that modest amounts of exercise, i.e. walking three times a week for people
aged 60 to 80 showed significantly different rates of decline in cognitive
function and elasticity compared to those not taking such exercise. These
simple measures are surely worth spending money on, even if they make a relatively
small dent in the incidence of dementia.
Adopting precautionary principles and
taking earlier preventive actions are not part of the mindset of too many
policy makers and those in power – there are fewer votes in walking schemes
than there are in pouring money into hospitals. There’s even less profit to be made from walking schemes
or encouraging people to modify their drinking habits or to eat less
sugar. More floods ahead!
References:
Potts, L., Dixey,
R., Nettleton, S., (2008), Precautionary tales: Exploring the Obstacles to
debating the primary prevention of breast cancer, Critical Social Policy, 28,
2, 115-135
Potts, L., Dixey,
R., Nettleton, S., (2007), Bridging differential understanding of environmental
risk of breast cancer: why so hard? Critical Public Health, 17, 4, 337-350
