various aspects of the scientific paradigm of public health. ... The asbestos saga. ..... (the blood pressure expert who claimed that diseases and health risks.
POLITICS IS NOTHING BUT MEDICINE AT A LARGER SCALE
JOHAN MACKENBACH MARIANNE DONKER LEX BURDORF
9 January 2008 Department of Public Health Erasmus Medical Center University Medical Center Rotterdam
These essays have been written on the occasion of New Year’s dinner 2008 of the Department of Public Health of Erasmus Medical Center. This booklet forms the sixth in a series which explores various aspects of the scientific paradigm of public health. 2003: “Streets of Paris, sunflower seeds and Nobel prizes. Reflections on the quantitative paradigm of public health” (Johan Mackenbach) This essay has been published in full in the Journal of Epidemiology and Community Health (2004;58:734-737). 2004: “Kos, Dresden, Utopia …. A journey through idealism past and present in public health” (Johan Mackenbach) Parts of this essay have been published in the European Journal of Public Health (2004;14:113. “Thomas More, Etienne Cabet, and the paradoxes of utopian thinking”), the International Journal of Epidemiology (2005; 34:537-539. “Odol, Autobahne and a non-smoking Fuehrer: reflections on the innocence of public health”), Prävention und Gersundheitsförderung (2006;1:208-211. “Odol, Autobahnen und ein nicht-rauchender Führer”), and the Journal of Clinical Epidemiology (2005;58:433-435. “The survival of the altruistic trait in medicine: is there a link with the placebo effect?”). The essay has been published in full in the European Journal of Epidemiology (2005;20:817-826), with commentaries by M. Marmot, J. Olsen, H. Hense and O. Miettinen. 2005: “Myths of paradise, and other stories on where diseases come from” (Johan Mackenbach) Parts of this essay have been published in the European Journal of Public Health (2004;14:337. “Hendrikje van Andel, bristlecone pines, and why we die”), the Journal of Epidemiology and Community Health (2006;60:81-86. “The origins of human disease: a short story on ‘where diseases come from’”), and the Journal of Clinical Epidemiology (2007;60:105-109. “The Mediterranean diet story illustrates that “why” questions are as important as “how” questions in disease explanation”). 2006: “Brother wind, sister water. Public health on a finite earth” (Johan Mackenbach) Parts of this essay have been published in the European Journal of Public Health (2006;16:575. “Rene Dubos and Jared Diamond dream of Dutch polders”), the Nederlands Tijdschrift voor Geneeskunde (2006;150:1788-1793. “Mondiale milieuveranderingen en volksgezondheid”), the Journal of Epidemiology and Public Health (2007; 61:92-4. “Global environmental change and human health: a public health research agenda”) and the Scandinavian Journal of Public Health (2007; 35:1-3. “Public health ethics in times of global environmental change: time to look beyond human interests”). 2007: “Water as a source of health and disease. Three small pieces” (Johan Mackenbach, Sake de Vlas and Inez de Beaufort) The first piece has been published in part in the British Medical Journal (2007;334 Suppl 1:s17. Mackenbach JP. “Sanitation: pragmatism works”. ) The second piece is based on a paper submitted for publication (Sow S, Polman K, Vereecken K, Vercruysse J, Gryseels B, de Vlas SJ. “The role of hygienic bathing after defecation in the transmission of Schistosoma mansoni”). The third piece has been published in the J Publ Health (2007;15:407-412. de Beaufort I. “The camel phenomenon”).
Cover illustration: The Berlin barricades, March 1848.
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CONTENTS Johan Mackenbach. Public health’s biggest idea. Modern resonances of Rudolf Virchow’s revolutionary years. ……………… 5
Marianne Donker. Health care is politics on a smaller scale. Doctors should be more than canaries in the coalmines. …...………………. 29
Lex Burdorf. How can politics and public health learn from each other? The asbestos saga. …………………………………………….... 37
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Figure 1. Rudolf Virchow around 1848
Drawing by Ludwig Pietsch
Figure 2. The older Virchow on a stamp (1953)
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PUBLIC HEALTH’S BIGGEST IDEA -- modern resonances of Rudolf Virchow’s revolutionary years --
Johan Mackenbach
INTRODUCTION A visit to Berlin In the summer of 2007 I visited Berlin with my youngest son who – I hope – is developing an interest in history. One of our objectives was to go and see the “Treasure of Priamos”, the golden jewellery which Heinrich Schliemann found in 1873 in the place identified as Troy. We went to the Museum für Vor- und Frühgeschichte and looked for the jewellery in the Schliemann Saal, but sadly discovered that Berlin only has the replicas. The originals are in the Pushkin Museum in Moscow, where they are held as war booty for the damages inflicted onto the Soviet people by Nazi-Germany [1]. Still a bit confused by the bitter ironies of history we were about to leave the museum when I suddenly saw the name of the gallery next to the Schliemann Saal. There appeared to be a second hall of fame in this museum, called the Virchow Saal. I knew that Rudolf Virchow, in the words of his biographer Ackerknecht, was a “doctor, statesman and anthropologist” [2], but I had never heard about his work as a prehistorian. I soon discovered, however, that this homo universalis was even more universal than I thought. He has led prehistorical excavations in Germany and the Caucasus (some of the finds are on show in the museum), he assisted Schliemann in Egypt and Troy, and he was a cofounder of the Deutsche Gesellschaft für Anthropologie, Ethnologie und Urgeschichte [3]. The first time I came across the name of Rudolf Virchow was when I was a medical student. Although the history of ideas is usually ignored in the medical curriculum, my pathology textbook honoured Virchow as the founder of cellular pathology. This is the theory that all diseases can be understood from the functioning and malfunctioning of cells. This revolutionary idea replaced age-old humoral pathology, the theory that diseases originate from a disbalance between four bodily juices. Although molecular pathology is now gradually replacing cellular pathology, many of Virchow’s basic ideas still hold true, such as the 5
notion that disease is an expression of normal life processes under abnormal circumstances [4]. The second time I came across Rudolf Virchow was when I entered public health. Similar to John Snow, who is a hero both of anaesthetics and of public health, Rudolf Virchow is a hero both of pathology and of public health. He is regarded as one of the founding fathers of social medicine, which is the continental-European precursor of modern public health. The 4th edition of our textbook for medical students Volksgezondheid en gezondheidszorg even cites Virchow’s famous “Medicine is a social science, and politics nothing but medicine at a larger scale” on two occasions [5]. This is perhaps excessive, but reflects the fact that it is public health’s biggest idea: human health and disease are the embodiment of the successes and failures of society as a whole, and the only way to improve health and reduce disease is by changing society and, therefore, by political action. Geoffrey Rose’s big idea An editorial in the British Medical Journal called a modern version of the same idea “Geoffrey Rose’s big idea” [6]. Geoffrey Rose is indeed a modern champion of Virchovian ideas, as illustrated by the final sentence of his important book “The strategy of preventive medicine”: “Medicine and politics cannot and should not be kept apart”. His reasoning is that we should focus on variations in population health instead of variations in the health of individuals. As soon as we do that, we will see that ill-health is caused by economic, social and cultural factors which can only be addressed by collective action [7]. The purpose of this essay is to retrace the origins of this idea, which has recently become even more popular than it already was, as can be seen in, among other things, the international movement towards “health in all policies” [8] as well as in inaugural addresses of newly appointed professors of social medicine or public health in the Netherlands [9,10]. My analysis will focus on Rudolf Virchow and his legacy, and try to determine how these ideas arose, and what their modern resonances are.
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RUDOLF VIRCHOW AND THE REVOLUTION OF 1848 New biographies for an old hero Rudolf Virchow, who was born in 1821 as son of a lower middle class family, has been famous for most of his life, and is still one of the great intellectual heroes of the 19th century. Although he did not write an autobiography, he did write extensive memoirs which were published on the occasion of his 80th birthday in 1901 [11]. Even before that, short biographies had appeared on the occasion of his 70th birthday, and after his death in 1902 his followers published several more [12]. Attempts at a comprehensive interpretation of his life and works only appeared several decades later, but were often politically coloured. A biography published in Nazi-Germany in 1940 played down his political life, while studies published in the German Democratic Republic liked the “young revolutionary Virchow” and criticized his later “reactionary” political activities [12]. I was surprised to discover some of the latter criticism in the old brochure which the Museum für Vor- und Frühgeschichte still sells to visitors interested in Virchow’s work as a prehistorian. This brochure was written before the Wende and explicitly mentions his “lack of dialectical insight” [3]. It is difficult to avoid projecting the present onto the past, as is also illustrated by the widest known biography in the English-speaking world which I already referred to above. Ackerknecht, who had fled from NaziGermany in 1933, portrays Virchow as representative of a different, liberal Germany, and emphasizes his “civic courage” which according to the author had become more and more rare after 1848, and “reappeared in a small minority (…) in the dark ages of Nazism” [2]. We are now perhaps in a better position to judge Virchow on his own merits, not only because of a lesser need to claim him for one or the other ideology, but also because new biographies have appeared. These make fuller use of archival materials which before German reunification were separated between East- and West-Germany [12,13,14]. Like the “Treasure of Priamos”, some had even been held in the Soviet Union. The trip to Upper-Silesia Nevertheless, it is good to start with Virchow’s own memoirs. In his Zur Erinnerung Virchow describes the extraordinarily wide spectrum of his activities, and emphasizes that this mixture of medicine and anthropology, politics and prehistory is “neither arbitrary nor tendentious”. The key event which, in his own view, inspired him to all these activities was a trip which he made to Upper-Silesia in early 1848, to conduct an official investigation into the causes of a typhus epidemic.
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In the winter of 1847/1848 this region had suffered from a severe epidemic which caused 16,000 deaths. Because the Prussian bureaucracy feared the unrest which this would likely cause, it sent an official commission into the area to investigate the causes. The commission left on the 20th of February and returned on the 10th of March. Virchow, who already was a medical authority at the age of 26, was a member of this committee, and wrote the main report, Mittheilungen über die in Oberschlesien herrschenden Typhus-Epidemie, which was published later in the same year [15]. In this report, he not only established the medical diagnosis of the disease (spotted fever, now known to be caused by Rickettsia transmitted by the human body louse, and not typhoid fever, now known to be caused by Salmonella transmitted by faecal contamination of food and water). He knew this type of typhus to be associated with hunger and war, and identified the deeper causes of the epidemic as social and, ultimately, political. The direct cause of the epidemic was the famine of the previous years, which in its turn was due to crop failures because of bad weather. The effects of the famine were, however, concentrated among the poor, who were predominantly Polish peasants. In Virchow’s analysis their poverty, which was closely associated with their lack of schooling, originated from political oppression by the reigning bureaucracy, and from economic oppression by the local aristocracy. Therefore, Virchow argued, elimination of this social inequality is the only way to prevent typhus epidemics in the future [15]. The Springtime of Peoples In the above I have mentioned the precise dates because they help to see the broader historical context of the Upper-Silesia investigation. The years immediately preceding 1848 had seen crop failures, famine and epidemics throughout Europe. To mention just the example of the Netherlands: the years 1845 to 1848 were years of potato blight, a plague of mice, very cold winters, and cholera. Many countries had already seen food riots, and the general expectation was that more was to follow. In January 1848 Karl Marx wrote his Communist Manifesto in which he predicted a general revolution, and indeed revolts broke out on the 23rd of February in Paris, on the 13th of March in Vienna, on the 18th of March (8 days after Virchow’s return) in Berlin, and on the 24th of March in Amsterdam. (The latter had a limited character only, and revolutionary tendencies in the Netherlands were cut short by the King’s initiative to ask Thorbecke to design a new Constitution, which was rapidly approved on the 13th of April [16]). The Berlin revolt is one of the famous episodes in Virchow’s biography. Calls for freedom of press and for democratic reforms were 8
followed by the Prussian King’s announcement on the 19th of March that he would revise the Constitution, but while this was announced shots were heard, and the ensuing panic led to a barricaded battle between civilians and the military. In the night of the 19th of March, Virchow himself defended a barricade on the corner of Friedrichstrasse and Traubenstrasse, using an old pistol he had borrowed from a medical colleague. In a letter to his father he wrote that he had been unable to do anything useful, because the opposing soldiers had stayed too far away [14]. Towards social medicine During the rest of the same year Virchow remained politically very active, and participated in a variety of democratic, republican and socialist movements. At the end of the year he wrote to a friend that he had been working like a draft horse, and it is not difficult to see how he must have felt, because on top of his scientific work as a pathologist and of his political activism he was also engaged in a medical reform movement. This aimed at creating a unitary profession and at improving the material position of medical doctors, by giving them the same legal status as civil servants. In order to support their claims, Virchow created a weekly journal called Die medicinische Reform which appeared between July 1848 and June 1849. The medical reform movement did not restrict itself to issues relating to the social position of medical doctors, but also propagated the scientific method as the basis not only of medicine, but also of all social and political activities [13]. It is around this nexus of ideas that many of Virchow’s most famous quotations cluster. “If medicine is the science of man both healthy and ill, which after all it should be, what other science could then be more appropriate to deal with law-making, in order to apply the laws that are given in mankind’s nature to the foundations of the organization of society?” In these opinions he closely followed his two years older colleague Salomon Neumann, who had declared that “medical science is in its innermost core and essence a social science” [17]. This idea had been developed in the 1830s by French doctors, and led Jules Guérin to coin the term médecine sociale in two papers in the Gazette médicale de Paris published on 11th and 18th of March 1848. Not to be confused with médecine socialiste, médecine sociale refers to the totality of the relations between medicine and society [18]. In a piece on Poor Law Doctors published in Die medicinische Reform in July 1848, Virchow wrote that doctors are “the natural attorneys of the poor”. In another piece on the same topic, published in November 1848, he finally writes the famous one-liner “Medicine is a social science, and politics nothing but medicine at a larger scale” [19]. 9
Table 1. Some quotations from Virchow in the original language (1848) “Als Naturforscher kann ich nur Republikaner sein, denn die Verwirklichung der Forderungen, welche die Naturgesetze bedingen (…), ist nur in der republikanischen Staatsform wirklich ausführbar.” “Den Communismus als solchen halte ich (…) für Wahnsinn, wenn man ihn direkt herstellen wollte. Den Socialismus dagegen erkenne ich als das einstige Ziel unserer Bestrebungen.” “Die Aerzte sind die natürlichen Anwälte der Armen und die sociale Frage fällt zu einem erheblichen Theil in ihrer Jurisdiction.” “Wer kann sich darüber wundern, dass die Demokratie und der Socialismus nirgend mehr Anhänger fand, als unter den Aerzten?” “Die Medicin ist eine sociale Wissenschaft und die Politik ist weiter nichts als Medicin im Grossen.”
Figure 2. The title page of Virchow’s study of typhus in UpperSilesia (1848)
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It is beyond the scope of this essay to summarize the rest of Virchow’s long life after 1848. Let it suffice to say that Virchow’s political stand led to his discharge from the Charité Hospital in March 1849, but after some years spent in exile in Würzburg, where he developed his ideas about cellular pathology, he returned to Berlin to take up a position as Professor of Pathology at the Charité in 1856. In 1859 he was elected a member of the Berlin Community Council, which he remained until his death in 1902. In 1861 he was also elected a member of the Prussian parliament, where he often disagreed with Bismarck who once when he felt insulted by Virchow challenged him to a duel which the latter refused. While continuing his scientific work as a pathologist, and later as an anthropologist and prehistorian, the politician Virchow fought for safe drinking water supplies and sewage removal, for hygiene in slaughter houses and for new hospitals, for children’s vaccinations and for gymnastics lessons for girls [12,13]. Cells and citizens, doctors and politicians Was there a connection between Virchow’s work in cellular pathology and his ideas about public health? There certainly was: his pathological theories inspired his political theories, and vice versa. In his pathological work he often used political metaphors, for example when he described the living organism as a “free state of individuals with equal rights, although not with equal talents, which is kept together by the fact that the individuals depend on each other”. In his Cellularpathologie, which appeared in 1858, he writes that the biological organism is a “kind of social organization”, a “societal unity, and not (…) a despotic or oligarchic unity”. “The cell can claim to be the real citizen, the legitimate representative of the singularity of existence, just like we claim to be this in human society, in the state (…).” [20]. Similarly, society and the state are described in terms of biological metaphors. For him, the state was a living organism consisting of individual beings who cooperate for mutual benefit. Just as he emphasized the autonomy of the cell within biological organisms, he also emphasized the autonomy of individual human beings as members of society, who should have equal rights and not be subordinated. For Virchow, the human body is the “ideal state of liberalism”, and the example of cells in the body provides the model for a “classless society of civilians” [12]. Virchow even went one step further. Just like disease is nothing but life processes occurring under unfavourable circumstances, so epidemics are collective illnesses which are “indications of large disturbances of collective life”. “Each time when many people find themselves in similar, disadvantageous circumstances, many will fall ill, 11
and diseases will be endemic or epidemic”. Some of these epidemics are “artificial”, because they are “attributes of society (…); they signal deficits which are generated by the organization of state and society and therefore preferably strike those classes which do not enjoy the advantages of culture.” “Epidemics resemble big warning signs, on which the statesman of great stature can read that the development of the population has met a disturbance which even carefree politics can no longer overlook.” [12]. Statesmen had always liked to see themselves as doctors at the sickbed of society. The British reformer Jeremy Bentham (1748 - 1832) wrote that “the art of legislation is but the art of healing practised upon a large scale. (…) It is the common endeavor of both to relieve men from the miseries of life. But the physician relieves them one by one; the legislator by millions at a time.” [21]. Virchow now turned this longstanding metaphor upside down: he actually sees medical doctors as the better statesmen. He was therefore glad to see that so many doctors were engaged to be radical democrats: “Who can be surprised to see that democracy and socialism nowhere find more supporters than among medical doctors, and that everywhere among the extreme left, partly at the head of the movement, medical doctors can be found?” Many members of the first freely elected parliament were indeed medical doctors, and most were ‘democrats’ or ‘radicals’ [14].
Figure 3. Virchow between his skeletons
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GEOFFREY ROSE AND THE EMERGENCE OF ‘POPULATION HEALTH’ Sick individuals and sick populations Although one will still find medical doctors in national parliaments and municipal councils, even in positions as presidents and prime ministers, no-one will seriously contend that medical doctors are better statesmen than men and women from other scientific disciplines. They may not be worse either, but we no longer consider analogies between biology and sociology to be a reliable basis for political decisions. This part of Virchow’s big idea is certainly out-of-date. That does not necessarily apply to the other parts, however, particularly the notions that whole populations can be sick, and that political action may be needed to improve population health. Let’s start with the first. Geoffrey Rose (1926-1993), professor of epidemiology at the London School of Hygiene and Tropical Medicine, is the modern champion of this idea. In the very first paragraph of his book “The strategy of preventive medicine” he already discloses his Virchovian inspiration, when he cites Rudolf Virchow as saying that “epidemics appear, and often disappear without traces, when a new culture period has started. (…) The history of epidemics is therefore the history of disturbances of human culture.” [7]. According to Rose he got his main ideas from George Pickering (the blood pressure expert who claimed that diseases and health risks come in all grades of severity, and represent a continuum instead of a binary phenomenon [22]) and Ancel Keys (the principal investigator of the Seven Countries study who showed that the entire distribution of risk may be shifted in one population as compared to the other, suggesting that whole populations may be ill [23]). Based on their work, Rose developed the idea (a) that there is indeed something like population health, (b) that the causes of incidence (population-level illness) are different from the causes of cases (individual-level illness), (c) that a mass approach to prevention is better than a targeted approach, (d) but that it suffers from the paradox of prevention (i.e., the benefits for the population as a whole may be large, while the benefits for the individual are small), and (e) that it requires collective intervention and therefore political action. For now, we need not be concerned with parts (c) and (d), although they are highly relevant for public health policy and practice, and we will focus on parts (a) and (b). Rose developed these ideas in a paper published in 1985, titled “Sick individuals and sick populations” [24]. His argument focuses on the observation that epidemiology’s dominant
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research strategy is to study variations between individuals: cohort studies compare individuals with and without a certain exposure to see whether the exposed have a higher risk of developing a disease; casecontrol studies compare individuals with and without a disease to see whether the diseased have more often been exposed. “But we should not forget that the more widespread is a particular cause, the less it explains the distribution of cases. The hardest cause to identify is the one that is universally present, for then it has no influence on the distribution of disease.” He then takes the example of the systolic blood pressure distributions of Kenyan nomads and London civil servants – which hardly overlap, with Kenyan nomads having much lower blood pressures than London civil servants – to argue that with conventional epidemiological studies we “might achieve a complete understanding of why individuals vary, and yet quite miss the most important public health question, namely, ‘Why is hypertension absent in the Kenyans and common in London?’. The answer to that question has to do with the determinants of the population mean.” “Case-centred epidemiology identifies individual susceptibility, but it may fail to identify the underlying causes of incidence.” “The clues [to the causes of incidence] must be sought from differences between populations or from changes within populations over time.” [24] The social physics of crime and suicide In his book, Rose notes that the idea that healthiness is a characteristic of a population as a whole, and not only of its individual members, can already be found with the French sociologist Émile Durkheim (1858 – 1917), who wrote that “each society is seen to have its own suicide rate”. While suicide seems to be a highly individual decision, national suicide figures vary by a small number only from year to year, expressing “the tendency to suicide with which each society is collectively afflicted” [25]. This is indeed a striking phenomenon that still can be observed: in the Netherlands, for example, the number of people commiting suicide was 1500 in 2003, 1514 in 2004, 1572 in 2005, and 1524 in 2006 [26]. It is as if the individual risks of suicide are somehow constrained by the population rate of suicide, instead of the population rate being simply the sum of individual risks. This idea was popular among scientists in the second half of the 19th century, and may also have found its way into Virchow’s thinking. It is exemplified by the work of the Belgian astronomer Adolphe Quetelet (1796 - 1874) who tried to apply the laws of physics (not even the laws of medicine or biology!) to the study of society. He did not only invent the Quetelet Index, but also noted statistical regularities in wilful acts such as 14
crimes, which suggested to him that crime is caused not by wickedness but by society. Free will is an illusion, which will be dispelled by better knowledge of the laws governing human life. In Quetelet’s mechanistic view there must be some underlying force which makes people break the law until the yearly quota are fulfilled [27]. This is of course an exaggerated notion, and it is not necessary to believe in such stark ideas in order to see that population health may be more than the sum (or average) of the health of all individuals making up that population. There are two ways in which this can be true – one in which population health is defined to be different, and one in which population health (despite a similar definition) is found to be different from the sum of the health of individuals. ‘Emergence’ Health and disease are usually seen to be properties of individual organisms: a human being (or a cat, or a plant) can be healthy or ill, and in case of illness of a human being doctors will try to identify the underlying ‘disease’. Medicine has long been dominated by ‘ontological’ theories of disease, i.e. theories in which diseases had an existence independent or separate from the suffering organism. It was Rudolf Virchow who finally declared that “diseases have no independent or isolated existence; they are not autonomous organisms, not beings invading a body, nor parasites growing on it; they are only the manifestations of life processes under altered conditions”. Since then, ‘disease’ is seen as an attribute of an organism – a set of abnormal manifestations which result from reactions of the organism to a wide variety of disturbances, and which produce some kind of disadvantage in the organism’s functioning [28]. In biology, the organism is just one of the many levels of organization at which life processes can be studied. Organisms consist of organs, organs consist of cells, and it would not be difficult to conceptualize healthy organs and sick cells. Similarly, organisms themselves are part of even larger systems, i.e. of populations, which are themselves the constituent part of ecosystems [29]. Can we conceptualize sick populations? Perhaps we can, and not only in a metaphorical sense. The Russian population exhibits ‘abnormal manifestations’ (a high mortality rate) which result from ‘reactions to disturbances’ (a high prevalence of excessive alcohol consumption, caused by wide-spread demoralization and a culture permissive of alcohol intoxication), and which produce a ‘disadvantage in its functioning’ (great losses to labour productivity) [30]. The main requirement is that we see populations (i.e., groups of individuals of one kind of organism) as ‘systems’ (i.e., interdependent components whose 15
interaction is controlled by positive and negative feedback mechanisms), whose over-all functioning (in terms of, e.g., reproduction, growth, prosperity, …) can be impaired. But even if we define population health more simply as the aggregate of the health of all individuals making up that population (e.g. as the number of new cases of disease which occur during a certain time-period), it can be seen that population health will not necessarily be a linear function of individual health. The ‘emergence’ of new characteristics at higher levels of organization is the subject of complexity theory, the theory that tries to understand the generation of rich, dynamical collective behaviour from the interactions between large numbers of subunits [31,32]. Take the example of infectious diseases: because one case will lead to another, (aggregate) future incidence will be more than the sum of (individual) current cases [33,34]. More generally, transmission of the causes of disease between individuals (micro-organisms, suicidal thoughts, violence, smoking, perhaps obesogenic behaviour [35]) leads to positive feedback loops generating ‘emergent’ properties at the aggregate level, which cannot be readily deduced from what happens at the individual level. More generally still, all positive feedback mechanisms (not only direct transmission of disease between individuals, but also indirect effects of disease on others’ health, e.g. through economic performance) will let population health diverge from the aggregate of individual health statuses [27]. The epidemiology wars So was Rose right? The concept of ‘population health’ has certainly gained some momentum recently, as is evident from a number of books with this term in their title [36,37], but none of their authors go so far as to claim that population health is conceptually different from individual health. As indicated above, I think that there is room for a weak version of the idea that “sick populations” exist alongside “sick individuals”, and not only in a metaphorical sense. But the main question is whether this leads us to new knowledge about the causes of ill-health, and to new entry-points for public health interventions. It is on this issue that controversy has arisen, and Rose’s idea that we need to study characteristics of populations, not characteristics of individuals, has become a central theme in what some have called the ‘epidemiology wars’ [38]. This dispute, which raged in the second half of the 1990s, is about what are the most important causes of disease. Many epidemiologists preferred to study specific environmental exposures, health behaviours, biomedical characteristics and other ‘proximal’ causes of disease, which are specific to the disease at hand and which can readily be examined with individual-level data in within16
population comparisons, are to be given priority, because of the greater scientific certainty about the role they play in disease etiology [39,40]. Others, echoing Rose, criticized this approach and argued that the more ‘distal’ or ‘upstream’ causes which will typically be identified in betweenpopulation comparisons, such as poverty, social cohesion or economic development, are more important because they offer greater potential for prevention strategies [41,42]. A preoccupation with individual-level risk factors makes modern epidemiologists “prisoners of the proximate” [43]. But the first group then raised the rhetorical question: “Should the mission of epidemiology include the eradication of poverty?” “The further upstream we move from the occurrence of disease towards root causes, the less secure our inferences about the causal path to disease become. Even if our inference is correct, intervention with respect to upstream causes may be less (…) effective than intervention closer to disease occurrence.” “Is poverty eradication a public-health programme? How exactly should it be accomplished? Economists would seem the most likely candidates to supply the answer.” “Given the scope of the task, sympathy might go to the epidemiologists who prefer to focus on a comparatively simple problem, such as the causes of cancer.”[44] Some of Geoffrey Rose’s critics have said that “The vision of a ‘sick population’ points towards a total ‘medicalization’ of human life in all its aspects, and an unlimited expansion of the concept of ‘health’ until it becomes meaningless except as a tool of political rhetoric.” [39] It is time, therefore, to look at the political implications in more detail.
Figure 4. Adolphe Quetelet on a stamp (1974)
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IS THERE A MODERN VIRCHOW? THE REVOLUTION OF 1968 AND ITS AFTERMATH Health in All Policies Whatever the merits are of Geoffrey Rose’s big idea, the idea that ‘medicine’ needs ‘politics’ to improve population health is more popular than ever. In this specific sense, ‘politics’ refers to the process by which governments make decisions about ‘policies’, deliberate plans of action to achieve certain outcomes. In a parliamentary democracy, it is in the ‘political arena’ of cabinet and legislature that decisions about policy are made, often as a compromise between the ideologies and interests of the political parties involved [45]. During the past decades, the idea that health needs to be brought into these political arenas has become part of mainstream public health, perhaps because simple technical fixes for today’s great public health challenges seem to be out of reach. Nowhere can this be seen more clearly than in the field of health promotion. After the epidemiological transition, many of the health problems of high-income countries are caused by behavioural risk factors which are difficult to change: smoking, lack of physical exercise, inadequate fruit and vegetable consumption, excessive alcohol consumption, unsafe sex, … [46]. How to change these seemingly voluntary behaviours? The field of health promotion has gradually evolved from an approach focusing on the social psychology of individual life-styles, to an ecological approach in which higher levels of influence on health behaviour are taken into account as well, including institutional and community factors and public policy [47]. The Ottawa Charter for Health Promotion calls for the creation of health-promotive environments, which requires multisectoral action and, in the end, political action: “Political change is a necessary component for the success of many multilevel behavioural change interventions” [48]. For example, political action is needed to stem the obesity epidemic, because only this can provide an effective countervailing power against the influence of the food industry [49]. A recent document on “Health in All Policies”, prepared for the European Commission, has outlined these ideas in more detail [8]. “Health is an outcome of a multitude of determinants, including those relating to (…) individual lifestyles, the environment, culture, and societal structures and policies. (…) The HiAP approach is to take into account the health impacts of other policies when planning policies, deciding between various policy options and implementing policies in other sectors. (…) Public and political support is essential for health implications to be taken into serious consideration in policy-making.” [8]
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As a matter of fact, this idea already has a strong foothold in many modern textbooks of public health [50-52], and “influencing government policy” has become a standard ingredient of handbooks of public health practice [53]. Not-so-silent victories When we look at the great victories of public health of the 20th century, there are indeed many examples of interventions and policies that were decided upon in the political arena. Although they have been described as “silent victories”, in the sense that the lives saved and years extended by public health were anonymous [54], many interventions and policies were controversial and required extensive debate before they were implemented. Obstacles to be overcome included resistance to constraints on personal freedom, powerful economic interests, inequitable distributions of economic and social resources, and tensions between national and local authorities [55]. Control of infectious diseases through safe drinking water supplies and sanitation often required decisions by municipal governments – decisions in which Virchow was involved in Berlin. Many other measures, such as introduction of mass vaccinations, prevention of occupational exposures and injuries, introduction of water fluoridation, motor vehicle safety measures, and tobacco control, were implemented through special legislation and required the allocation of tax money. Although the development of these measures was largely a matter of scientific and technical progress, they could not be implemented at a larger scale without passing through a stage of political decision-making. Often, these decisions were controversial, as in the case of water fluoridation where many jurisdictions including the Netherlands’ government finally decided for another, less collective approach [55]. One area that is inherently politically controversial is that of socioeconomic inequalities in health. Any analysis of the causes of health inequalities must point to the connection with social and economic circumstances, and change in the latter requires the active commitment of national and local governments. The area of health inequalities was core to the work of Virchow, Villermé, Chadwick and many other 19th century forefathers of public health, and has recently been revived, particularly after the publication of the Black report in England in 1980. This report, which had been commissioned by a Labour government, was issued after a Conservative government had come to power, and was largely ignored because its recommendations were politically unwelcome. As most other reports on health inequalities it concluded that the latter were caused by inequalities in income and other material or structural circumstances. It therefore recommended a redistribution of 19
income and various other ‘upstream’ policy measures that did not fit into the neoliberal agenda of the Thatcher government [56]. In the Netherlands, a government advisory committee on health inequalities which had carefully tried to avoid politicization of its analysis and recommendations, met a similar fate. Its report was issued just before the elections brought a Center-Right government into power, and the recommendations went into a desk drawer [57]. A “ladder of political activism” While not all public health issues are inherently politically controversial, a naïve observer cannot fail to notice that the outcome of political action to promote population health is rather uncertain. Politics is a struggle between conflicting ideologies and interests, in which health provides only one of many types of argument. Politics operates on a time-scale governed by elections and media attention, which is at odds with the greater time-scale at which population health and its determinants can be expected to change. An emphatically political approach to public health may also in the long run prove to be a selfdefeating strategy, because of the dangers of politicization. Politics is divisive, and long-term support for public health can be eroded as well as strengthened by recurrent political debates. How far should one go? Readers must decide for themselves, perhaps thinking of an imaginary “ladder of political activism” with four rungs. The first or lowest rung is that of political passivism: information on health risks and opportunities for health improvement is exchanged within the health sector only, and politicians are only informed if they ask for it. On the second rung, public health professionals actively disseminate relevant information among politicians, e.g. by addressing their reports to the government, by drawing the attention of the media, and by participating in advisory committees. If they choose to rise to the third rung, public health professionals will try to directly influence the political process, e.g. by lobbying and by actively engaging politicians of specific political parties. On the highest or fourth rung, public health professionals become politicians themselves, and try to obtain positions in government or parliament to reach their objectives. Many public health professionals will probably feel most comfortable on the second rung, but Virchow was among those who went to the top of the ladder, and he was (and is) in good company. Suppose that some readers would like to do the same – what political party should they choose? Evidence-based decision-making is even more difficult here than it is elsewhere, because there is almost no empirical evidence on the association between political traditions and population health. The little that there is, however, suggests that socialist 20
or communist parties (e.g. in the case of Cuba or China) have done relatively well in the Third World [58]. In line with this, “social medicine” in Latin America is more or less synonymous with “socialist medicine” [59,60]. In high-income countries, social-democratic parties appear to have done better than christian-democratic or liberal parties [61,62]. One recent analysis suggests that OECD countries which have mainly been governed by social-democratic parties not only have less income inequality but also lower infant mortality [62]. It is difficult to be sure about the causality of these associations, if only because populations consistently voting for social-democratic parties must also be different in many other respects. There is also no clear evidence that these countries have smaller health inequalities [63], but the results are certainly intriguing … The romantic revolution Those who are considering to climb the “ladder of political activism” should be aware of the fact that romantic illusions lie in wait -- romantic illusions which are characteristic for another revolution, that of May 1968. Like 1848, 1968 was an amazing year. In March, French students led by Daniel Cohn-Bendit occupied the university buildings in Nanterre, a Paris suburb. In April, German student leader Rudi Dutschke was heavily wounded by a shot in the head in Berlin. In May, students occupied the Sorbonne and erected barricades in the streets of Paris, in an anarchist spirit which aimed to remove and humiliate authority. Many of their romantic slogans have become famous: “Under the pavement lies the beach”, “Power to the imagination”, “Be realistic, ask the impossible”. The student riots sparked off a nationwide series of strikes, like those in the Renault factories, aimed at improving the stifling working relations. At first taken back by the events, French president De Gaulle announced a rapid election in which the ruling Gaullist parties won a crushing victory. Hereafter the workers returned to work and the students went on vacation [64,65]. Some of the causes of these events are simply demographic: there had never been such large numbers of young people, and because of better educational opportunities they were entering the universities in huge numbers. Post-war economic growth had freed most people in North America and Western Europe from immediate material concerns, and had allowed the development of a specific youth culture. Younger generations stood increasingly apart in cultural terms, and blamed older generations for their lack of resolve in coming to terms with the Second World War [66]. There are many parallels between the 1848 and the 1968 revolutions. Like so many other revolutions since 1789, both had their 21
epicentre in Paris. Both spread surprisingly rapidly from Paris to other European capitals. Both were revolutions of intellectuals (who campaigned for intellectual freedom in 1848 and against authority in 1968) and the working classes (who campaigned against hunger in 1848 and for more influence in the workplace in 1968). Both were complete failures (in terms of immediate political changes), but also marked important long-term changes in mentality. The main change in mentality around 1968 was that authenticity and self-development came to be seen as the yardstick against which all of life had to be judged. This was, to a large extent, a reaction to the authoritarian ideologies which were seen to be responsible for the Second World War and its crimes. Personal responsibility, on the basis of principles chosen by the individual, should now form the basis for society. This implied that everybody had to come to terms with the problems of the world, and had to make political choices [16,64]. Even seemingly personal matters like gender roles became politicized: according to leading feminists, “the personal is political” [67]. The political arena itself became more polarized, and the Left side of the political spectrum saw a revival of Marxism in various forms. Turning away from the ideologies of their parents which seemed the cause of so much evil, from unsolved fascist legacies to unbridled consumerism, and from the repression of women to persistent social inequalities, young people around the world found an alternative in Marxism, which seemed to offer an intellectually more satisfactory outlook on the modern world [66]. A discipline without borders According to many, the ‘makability’ of society has proved to be a romantic illusion, but as indicated earlier, politics does sometimes make a difference for population health. It is in more extreme circumstances that the effects of politics are most plausible. This is illustrated by the work of a man who comes as close to a modern Virchow as one can get: Bernard Kouchner. He is not a homo universalis who combines first rate medical science with at least one other scientific discipline plus high-profile politics, but he certainly has some elements of a Virchovian profile. Bernard Kouchner was born in 1939, as the son of a Jewish father and a Protestant mother. His father was a doctor with communist sympathies, and Bernard grew up to become a doctor and a communist himself. In his communist years, the early 1960s, he worked together with Régis Debray, through whose book “Revolution in the revolution?” Che Guevara became popular in Western Europe. Guevara was another medical doctor with revolutionary inclinations, who collaborated with Fidel Castro in the Cuban Revolution in 1958. He then went on to export 22
armed revolution into Latin America. He was killed in 1967, but posters with his bearded face could be found long after that year in many student accommodations throughout the western world [68]. Kouchner was a democrat, but dedicated his medical thesis, on the nutritional diseases of starving Africans, to his admired colleague Dr Guevara. He took part in the Paris uprisings in May 1968, but decided later in the same year to join a Red Cross mission into Biafra. This turned out to be what the trip to Upper-Silesia was for Virchow. In this province of Nigeria, a civil war had broken out in 1967, and a famine caused 600,000 deaths in three months. Kouchner concluded that the Nigerian government was to blame, because it followed a policy of exterminating the Biafra people, but the Red Cross wanted to maintain a neutral stance. After his return to France, he published a report and later decided to found Médecins sans frontières in 1971. This nongovernmental organization speaks out about the political decisions which sometimes cause humanitarian disasters, and was awarded the Nobel Peace Prize in 1999 [68]. Later, Kouchner became a full-time politician, he was Minister of Humanitarian Affairs and Minister of Health under François Miterrand, and developed into a strong advocate for the right to interfere in the “internal affairs” of nations for humanitarian reasons. This droit d’ingérence has been adopted to some extent in international affairs, and was put into practice in the former Yougoslavia, particularly in NATO’s action to stop the fighting in Kosovo in 1999. Kouchner became High Commissioner for Kosovo, in order to lead the transition to a peaceful situation. For similar reasons he was also in favour of the recent American/British invasion of Iraq … Although he still is a member of the Socialist Party, he is currently Minister of Foreign Affairs under CenterRight president Nicolas Sarkozy. Kouchner embodies the globalization of social conscience, which is perhaps best illustrated by his pleas for a system of global social security [69]. It is not difficult to find Virchovian resonances in his writings: “We were among those whom the misery of others did not leave inactive. (…) Medical doctor: this profession offers the advantage of a utility without frontiers and the interest of a universal ethic. If the patients, the sufferers, the unlucky called us, we came, particularly if it was forbidden, sometimes if it was impossible. This charitable action is profoundly political.” [70]
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Figure 5. Bernard Kouchner (left) and Daniel Cohn-Bendit in 2004
Cover illustration of ref. 69
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BY WAY OF CONCLUSION As this essay shows, Virchow’s legacy is still very much alive. His statement that “Medicine is a social science, and politics nothing but medicine at a larger scale” combines Guérin’s idea of “social medicine” with Bentham’s vision of legislation as “the art of healing practised upon a large scale”, and still resonates in modern public health. His idea that medical doctors make ideal politicians may be out-of-date, but the notions that whole populations can be sick and that political action is sometimes needed to improve population health still hold, although not necessarily in Virchow’s strong formulations. Virchow’s example also serves as a reminder that in order to understand population health we need a broad scope, which encompasses elements from medical science, as well as elements from other branches of science, including anthropology and prehistory if needed. Virchow moved from medical science to anthropometry, and from there on to anthropology and prehistory, in an attempt to understand mankind’s current health conditions from its biological and cultural antecedents. This broad scope is not only a necessity, but also a continuous source of joy for those who do not want to be locked up in a single discipline. References 1. Hänsel A. Heinrich Schliemanns Sammlung Trojanischer Altertümer. Berlin: Staatliche Museen zu Berlin, 2004. 2. Ackerknecht E. Rudolf Virchow. Doctor, statesman, anthropologist. Madison: University of Wisconsin Press, 1953. 3. Bertram M. Rudolf Virchow als Pähistoriker. Sein Wirken in Berlin. Berlin: Staatliche Museen zu Berlin, 1987. 4. Mackenbach JP. The origins of human disease. A short story on ‘where diseases come from’. J Epidemiol Comm Health 2006;60:81-86. 5. Mackenbach JP, van der Maas PJ (red.). Volksgezondheid en gezondheidszorg (vierde druk). Maarssen: Reed Elsevier, 2008. 6. Hofman A, Vandenbroucke JP. Geoffrey Rose’s big idea. Changing the population distribution of a risk factor is better than targeting people at risk. BMJ 1992;305:15191520. 7. Rose G. The strategy of preventive medicine. Oxford etc.: Oxford University Press, 1992. 8. Stahl T, Wismar M, Ollila E, Lahtinen E, Lepp K. Health In All Policies. Prospects and potentials. Helsinke: Ministry of Social Affairs and Health, 2006. 9. Van der Velden J. De toekomst van de public health. Rede uitgesproken bij de aanvaarding van het ambt van hoogleraar Public Health aan het Universitair Medisch Centrum St. Radboud. Nijmegen: Radboud Universiteit, 2004. 10. Stronks K. Maatschappij als medicijn. Rede uitgesproken bij de aanvaarding van het ambt van hoogleraar in de Sociale Geneeskunde aan de Universiteit van Amsterdam. Amsterdam: Vossiuspers, 2007.
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11. Virchow R. Zur Erinnerung. Blätter des Dankes für meine Freunde. Archiv für pathologische Anatomie und Physiologie und für klinische Medicin 1902;167(1):1-15. 12. Goschler C. Rudolf Virchow. Mediziner, Anthropologe, Politiker. Cologne etc.: Böhlau Verlag, 2002. 13. Andree C. Rudolf Virchow. Leben und Ethos eines grossen Arztes. Munich: Langen Mueller, 2002. 14. Balkhausen I. Der Staat als Patient. Rudolf Virchow und die Erfindung der Sozialmedizin von 1848. Marburg: Tectum, 2007. 15. Virchow R. Mittheilungen über die in Oberschlesien herrschenden TyphusEpidemie. Berlin, 1848. 16. de Rooy P. Republiek van rivaliteiten. Nederland sinds 1813. Amsterdam: Mets & Schilt, 2002. 17. Neumann S. Die öffentliche Gesundheitspflege und das Eigenthum. Berlin, 1847. 18. Guérin J-R. Aux Médecins de la France. Gazette Médicale de Paris 1848; March 11, p. 123. Guérin J-R. La Médecine sociale et la Médecine socialiste. Gazette Médicale de Paris 1848; March 18, p. 130. Both papers reproduced in: Deppe H-U & Regus M (eds.). Seminar: Medizin, Gesellschaft, Geschichte. Frankfurt: Suhrkamp 1975. 19. Virchow R. Der Armenarzt. Medicinische Reform 1848; nr. 18 (publ. 3.11.1848): 125-127. 20. Virchow R. Die Cellularpathologie in ihrer Begründung auf physiologische und pathologische Gewerbelehre. Zwanzig Vorlesungen, gehalten während der Monate Februar, März und April 1858 im pathologischen Institut zu Berlin. Berlin, 1858. 21. Porter D, Porter R (eds.). Doctors, politics and society: historical essays. Amsterdam and Atlanta: Rodopi, 1993. 22. Pickering GW. High blood pressure (2nd ed.). London: Churchill, 1968. 23. Keys A (ed.). Coronary heart disease in seven countries. American Heart Association Monograph 29. New York: American Heart Association, 1970. 24. Rose GA. Sick individuals and sick populations. Int J Epidemiol 1985;14:32-38. Reproduced, with 5 commentaries, in Int J Epidemiol 2001;30:427-432. 25. Durkheim E. Le suicide: étude de sociologie. Paris: Alcan, 1897. 26. Netherlands Statistics. Statline. Url: www.cbs.nl 27. Ball P. Critical mass. How one thing leads to another. London: Random House, 2004. 28. Kräupl Taylor F. The concepts of disease, illness and morbus. Cambridge: Cambridge University Press, 1979. 29. Odum EP, Barrett GW. Fundamentals of ecology. Fifth edition. Belmont: Thomson, 2005. 30. McKee M, Shkolnikov V, Understanding the toll of premature death among men in Eastern Europe. BMJ 2001;323:1051-1055. 31. Rickles D, Hawe P, Shiell A. A simple guide to chaos and complexity. J Epidemiol Comm Health 2006;61:933-937. 32. Kaufman S. At home in the universe. The search for laws of self-organization and complexity. New York etc.: Oxford University Press, 1995. 33. Koopman JS, Longini IM. The ecological effects of individual exposures and nonlinear disease dynamics in populations. Am J Publ Health 1994;84:836-842. 34. Koopman JS, Lynch JW. Individual causal models and population system models in epidemiology. Am J Publ Health 1999;89:1170-1174. 35. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. NEJM 2007;357:370-379.
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36. Young TK. Population health. Concepts and methods. Second edition. New York etc.: Oxford University Press, 2005. 37. Kunitz SJ. The health of populations. General theories and particular realities. New York etc.: Oxford University Press, 2007. 38. Schwartz S, Diez-Roux A. Commentary: Causes of incidence and causes of cases – a Durkheimian perspective on Rose. Int J Epidemiol 2001;30:435-439. 39. Charlton BG. A critique of Geoffrey Rose’s ‘population strategy’ for preventive medicine. J Roy Soc Med 1995;88:607-610. 40. Poole C, Rothman K. Our conscientious objection to the epidemiology wars. J Epidemiol Comm Health 1996;52:613-614. 41. Pearce N. Traditional epidemiology, modern epidemiology, and public health. Am J Publ Health 1996;86:678-683. 42. Susser M, Susser E. Choosing a future for epidemiology: II. From black box to Chinese boxes and eco-epidemiology. Am J Publ Health 1996;86:674-677. 43. McMichael AJ. Prisoners of the proximate: loosening the constraints on epidemiology in an age of change. Am J Epidemiol 1999;149:887-897. 44. Rothman KJ, Adami H-O, Trichopoulos D. Should the mission of epidemiology include the eradication of poverty? Lancet 1998;352:810-813. 45. Buse K, Mays N, Walt G. Making health policy. Maidenhead: Open University Press, 2005. 46. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global Burden of Disease and Risk Factors. Washington & New York: World Bank & Oxford University Press, 2006. 47. Sallis JF, Owen N. Ecological models of health behaviour. In: Glanz K, Rimer BK, Marcus Lewis F (eds.). Health behaviour and health education. Theory, research and practice. Third edition. San Francisco: John Wiley and Sons, 2002. 48. Ottawa Charter for Health Promotion. First International Conference on Health Promotion. Ottawa, 21 November 1986. Url: http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf 49. James PT, Rigby Leach R. The obesity epidemic, metabolic syndrome and future prevention strategies. Eur J Cardiovasc Prev Rehabil 2004;11:3-8. 50. Pomerleau J, McKee M (eds.). Issues in public health. Maidenhead: Open University Press, 2005. 51. Schneider MJ. Introduction to public health. Second edition. Sudbury: Jones & Bartlett, 2006. 52. Tulchinski TH, Varavikova EA. The new public health. An introduction for the 21st century. San Diego etc.: Academic Press, 2000. 53. Pencheon D, Guest C, Melzer D, Muir Gray JA (eds.). Oxford Handbook of Public Health Practice. Oxford etc.: Oxford University Press, 2000. 54. Winslow CEA. The evolution and significance of the modern public health campaign. New Haven: Yale University Press, 1923. 55. Ward JW, Warren C. Silent victories. The history and practice of public health in twentieth-century America. Oxford etc.: Oxford University Press, 2007. 56. Townsend P, Davidson N (eds.). The Black Report 1982. In: Townsend P, Whitehead M, Davidson N (eds.). Inequalities in health: The Black Report and the Health Divide. London: Penguin Books, 1992; pp 29–213
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57. Mackenbach JP, Stronks K. The development of a strategy for tackling health inequalities in the Netherlands. Int J Equity Health 2004; 3(1):11. 58. Navarro V. Has socialism failed? An analysis of health indicators under socialism. Int J Health Serv 1992;22:583-601. 59. Waitzkin H, Iriart C, Estrada A, Merhy EE. Social medicine then and now: lessons from Latin America. Am J Publ Health 2001;91:1592-1601. 60. Porter D. How did social medicine evolve, and where is it heading? PLoS Medicine 2006;3:e399. 61. Navarro V (ed.). The political and social contexts of health. Amityville: Baywood Publishing Company, 2004. 62. Navarro V, Muntaner C, Borrell C, et al. Politics and health outcomes. Lancet 2006;368:1033-1037. 63. Dahl E, Fritzell J, Lahelma E, Martikainen P, Kunst AE, Mackenbach JP. Welfare state regimes and health inequalities. In: Siegrist J, Marmot M (eds.), Social inequalities in health. New evidence and policy implications. Oxford/New York, Oxford University Press, 2006. 64. Judt T. Postwar. A history of Europe since 1945. London etc.: Penguin Books, 2005. 65. Mak G. In Europa. Reizen door de twintigste eeuw. nAmsterdam: Atlas, 2004. 66. Hobsbawm E. The age of extremes. The short twentieth century, 1914-1991. London: Abacus, 1995. 67. Hanisch C. The personal is political. 1969. Url: http://en.wikipedia.org/wiki/Carol_Hanisch 68. Berman P. Power and the idealists. Or, the passion of Joschka Fischer and its aftermath. New York: Norton, 2005. 69. Cohn-Bendit D, Kouchner B. Quand tu seras president … Dialogues et propos recueillis par Michel-Antoine Burnier. Paris: Robert Laffont, 2004. 70. Kouchner B. Les guerriers de la paix. Du Kosovo à l’Irak. Paris: Grasset, 2004.
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HEALTH CARE IS POLITICS ON A SMALLER SCALE -- doctors should be more than canaries in the coalmines --
Marianne Donker
INTRODUCTION 19th Century coalition of interests Politics may be nothing but medicine at a larger scale, but the medical profession nowadays seldom engages in politics to further the health of the population. Today’s doctors do not appear to be interested in political solutions for the ailments presented to them in their consulting room. They are politically active when their income is threatened, when nonphysicians enter the health care market, or when their professional quality is questioned by outsiders. This proves them human, but hardly resembles the revolutionary doctors of the 19th century like Virchow in Berlin, Von Pettenkofer in München, Villermé and Parent-Duchâtelet in Paris, Shattuck in Boston. These doctors entered politics to fundamentally improve living conditions for the deprived population of their time. Today, however, doctors tend to view individual therapy (i.e. their own activities) as the only pathway to health for their patients, spending no thought whatsoever on the social origins of disease or on social interventions to promote or protect health. In the 19th century, in all major European cities, the scientific foundations were laid on the connection between illness and social deprivation. But another insight was just as important, i.e. the realization that the ill health of parts of the population threatened the health of all others, as well as public safety and economic progress. The government took responsibility for improving the living conditions of the poor, seeing that this might benefit society as a whole. In a coalition between many interests, medieval charity was replaced by a revolutionary restructuring of society in all its physical and social aspects. We saw the rapid introduction of the sewer system, the provision of clean drinking water, schools for the poor, youth health care, improved housing for the working classes, safety at the workplace, and state allowances in case of unemployment or inability to work.
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De Swaan [1] demonstrates how these measures were not exclusively meant to improve the health status of the poor in the fast growing cities, although their impact on population health was enormous. A major motive was protection of the middle and upper classes from social unrest, crime and infectious diseases. In those days, doctors, engineers, architects and civil servants worked together and found ways to simultaneously serve many interests. Health was just one of the winners in the multiple win-win combination of this great socio-economic enterprise. Shift in focus De Swaan, however, also shows how since those early days the focus of the medical profession shifted away from collective arrangements toward healing individuals in private practice. Doctors became entrepreneurs in a health market. They even acquired the role of arbiter in fundamentally social problems such as unemployment caused by disability, trauma caused by war, or dissatisfied women imprisoned in their marriage. A curious reversal of focus took place: from attributing social causes to individual illness, towards individually treating illnesses that are essentially caused by social circumstances. Appeals for social engineering to further population health became the exclusive domain of university professors and municipal public health services, while the doctors locked themselves up within the walls of their consulting rooms.
BACK TO THE ROOTS OF SOCIAL MEDICINE Health is wealth In 2007, the Dutch Minister of Health Ab Klink, not a medical doctor but a sociologist, published his view on prevention and health promotion [2]. An important message in his policy is the connectedness between population health and general prosperity of the nation: ‘health is wealth’. The relationships works both ways: a nation needs a healthy workforce to thrive economically, and economic prosperity enhances health and wellbeing, as anybody who is conscious of the socio-economic origins of disease will easily recognize. Our Minister proposes to actively look for parallel interests, to design new policies that simultaneously serve the interests of health as well as those of the economy, environment, housing, transportation, safety, social cohesion, education, sports, etcetera. Ab Klink does not stand alone in his vision. The year 2007 was the year when this message was proclaimed by many others: Karien Stronks in her inaugural lecture [3], the European Observatory on Health 30
Systems and Policies in their plea for ‘Health in all policies’ [4], and David Hunter in his G-lecture [5]. Hunter, also not a medical doctor but a political scientist, agrees with Klink that more health care will not result in more health, and health issues should be connected to other big social issues. The 2006 Rotterdam public health policy has been a prelude to this trend: safety, economic vitality and social cohesion were connected to health goals, and a broad public-private coalition was proposed [6].
Reaction of the medical profession The medical profession in the Netherlands, however, does not seem to be very receptive to such a message. The Royal Dutch Society for Medicine (KNMG) in a recent policy document [7] on the one hand demonstrates awareness of the challenges. The KNMG recognizes the huge impact of smoking, inactivity, and unhealthy diets on population health, and professes to seek a coalition with the food industry, schools, insurance companies, as well as health care providers and citizens themselves. The proposed solution, however, is to position prevention in the domain of primary health care. General practitioners, in their contact with individual patients, should provide evidence based preventive interventions to patients most at risk. These interventions should be available to all, as part of the basic health insurance package. KNMG policy nowhere recognizes socio-economic health differences, nor can we detect any ambition to influence national policy to improve unhealthy living conditions (environment and industry, housing and workplace, traffic and transportation, etcetera). The KNMG sees doctors as the one-and-only solution to health inequalities. More or less the same conclusion applies to the National Association of General Practitioners (Landelijke Huisartsen Vereniging) [8]. They want extra money, generated from the basic health insurance, to provide patients with evidence based, preventive diagnostics. General practitioners should become active on the ‘prevention market’ to counteract the self tests available on the internet, and ‘health checks’ by non medical commercial parties such as health insurance companies. Even the Dutch Public Health Federation (NPHF) in their reaction to the 2007 Government Prevention Policy [9], after acknowledging the importance of the environment where people live and work, focuses primarily on policy measures in the domain of health care. For health care professionals, including public health care professionals, individually administered preventive interventions by the traditional health care providers (“geïndiceerde en zorggerelateerde preventieve interventies”) are the main focus for improving population health. No proposals whatsoever are made on collective interventions in other policy domains. 31
Present day challenges for collective action The collusion between the social structure of society and individual illhealth can be demonstrated with many examples. The social correlates of food intake and physical activity are well known, and recently we see the first efforts from the food industry, schools and employers to promote a healthier lifestyle. Policies to prevent tobacco and alcohol addiction recently focus on prohibitive laws and regulations, alongside the traditional educational mass media messages. These all demonstrate the growing awareness of the need to find solutions outside the traditional health care domain. I shall not dwell on these well known public health topics. But other major problems stare us in the face. Almost 900.000 persons receive a state allowance for unemployment because of their illness or handicap. In 1990 Prime Minister Lubbers rightly proclaimed our country to be sick (“Nederland is ziek”) because of this appalling number. Successive governments have not been able to substantially lower this figure, despite the obvious conclusion that there must be something wrong with the way we organize labour in our country. The debate, however, is between politicians, employers and labour unions. Doctors play no role whatsoever, except to examine whether individual patients are eligible for a disability pension. In other domains, policies with an impact on the health and wellbeing of many individuals also originate from outside the health care system. The Community Support Act (Wet Maatschappelijke Ondersteuning), for instance, became law on the waves of the new Christian Democratic policy, embodied since 2002 by Prime Minister Balkenende. The law makes municipalities responsible to provide practical support for chronically ill and handicapped people, enabling them to participate in the community. The aim is to reduce the role of the national government in society, with a simultaneous appeal on citizens to take responsibility for their own lives and the lives of their family and neighbours. The WMO heralds the demise of the welfare society (“verzorgingsstaat”). The new ‘civil society’ stresses the role of private enterprise, of community action, of ‘natural’ collective arrangements in neighbourhood, church, workplace or family. This new Christian policy believes in solidarity between people, in a charitable culture where people do the right thing without government coercion. The WMO, after initial scepticism now warmly embraced by the municipalities, might prove to be very influential in improving living conditions in neighbourhoods, for the chronically ill but also for others that are threatened with isolation and marginalization. The medical profession does not claim any role in this endeavour, and maybe rightly so.
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Other examples demonstrate the effectiveness of a coalition between the domains of public safety and health. In the four major cities of the Netherlands, a comprehensive programme is now under way to drastically reduce the number of homeless people and improve their health and living conditions. This ambition did not originate in the health care system itself, despite its awareness of the bad health and the poor living conditions of the homeless. It was first voiced in 2005 by the Minister of Finance together with a Salvation Army Major. Their humanitarian goals coincided with the goal to rid the streets of homeless beggars, an important issue in the political debate of the time which was dominated by concerns for public safety and crime. Only after the agenda was set, the health care sector, until then marginally treating the homeless for only the most obvious and pressing health problems, joined the program. With the extra money provided, special facilities were designed, including mental health care and addiction programs, integrated with housing facilities and work. A similar coalition was seen in the Rotterdam program for addicted street prostitutes. Until recently these cheap whores, addicted on all kinds of drugs, often ill, often with a personal history of parental neglect and child abuse, sometimes mentally retarded and with a psychiatric diagnosis as well, were allowed to work in specially designated areas.
Figure 6. Homeless people
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Figure 7. Syringes and condoms: signs of street prostitution
In these areas, doctors provided the most basic care for their health needs, with a special focus on preventing infectious diseases and ‘harm reduction’ i.e. reducing the adverse effects of addiction. Here, again, the ambition to put an end to the essentially degrading and inhuman conditions in these prostitution zones was a coalition between the goal of public safety and the belated political recognition that these prostitutes were mostly very ill women (and men) who needed protection instead of exploitation. In collaboration between police, (mental) health care and many others, prostitution zones were closed, and facilities for intensive treatment and rehabilitation were developed. After Rotterdam a number of other cities followed this policy. Domestic violence and child abuse, cause of many physical and mental health problems and source of many visits to general practitioners and emergency rooms, is another example that only recently reached the political agenda after years of silence from the medical profession about what they saw (or chose not to see) in their consulting rooms. Very few doctors have tried to call attention to these problems, despite the vast numbers and huge consequences, with the late Dries van Dantzig (psychiatrist in Amsterdam), Sylvie Lo Fo Wong (general practitioner in Rotterdam [10]) and Ben Rensen (child physician with the Utrecht Public Health Service) as the notable exceptions. The recent effort to really address this problem requires – again – the coalition between many parties, including the police and the public
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prosecutor, health care and schools, employers and youth welfare. The policy is not (only) to treat the victims, but most of all to prevent victimization and intergenerational transmission by promoting public awareness, early detection, comprehensive intervention in the afflicted families, and punishment of the perpetrators when necessary.
HEALTH AS A FELLOW TRAVELLER IN POLICYMAKING Canaries in the coalmines? There is nothing wrong with a concept of health that is closely intertwined with the concepts of general well-being of the population. On the contrary, it is ineffective to view health as the exclusive domain of health care professionals, to pronounce as suspect any health policy which does not originate with medical doctors. Seeking parallel interests, actively forging coalitions with other parties, finding the mutual ‘win’, may be the challenge for public health in the near future. The fact that we need others for such policy measures, however, does not exonerate the medical profession from actively participating in the political debate. The uneven distribution of health and illness in the population should make us aware of the uneven distribution of other goods in society, of dysfunctional mechanisms that support such inequalities, and also of ways to mend such wrongs. Doctors could be our canaries in the coalmines, signalling danger to politicians and thereby setting the political agenda. Their diagnostic abilities should be used more actively in the public domain. But signalling potential causes of illness and agenda setting are not the only goals. We do not just wish to put health on the agenda in its own right, or passively monitor health consequences of policies in other domains by promoting health impact assessment. The challenge is to actively seek win-win combinations in policy making, to join health goals with economic, social or environmental goals. This requires people with passion, willing to raise uncomfortable and controversial issues [11], people who are willing and able to cross borders and enter in dialogue with different organizations and professions [12, 13]. Unfortunately, training and social position of doctors are not very helpful to create such pioneers. The Virchow’s of our time will need to be found elsewhere. But in that respect history repeats itself. Even the famous Edwin Chadwick (1800-1890) was a lawyer! References 1. Swaan B de. Zorg en de staat. Welzijn, onderwijs en gezondheidszorg in Europa en de Verenigde Staten in de nieuwe tijd. Amsterdam: Uitgeverij Bert Bakker, 1990.
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2. Gezond zijn, gezond blijven. Een visie op gezondheid en preventie. Den Haag: Ministerie van Volksgezondheid, Welzijn en Sport, 2007. 3. Stronks K. Maatschappij als medicijn. Rede uitgesproken bij de aanvaarding van het ambt van hoogleraar in de sociale geneeskunde aan de Universiteit van Amsterdam. Amsterdam: Vossiuspers, 2007. 4. Stahl, Wismar M, Ollila E, Lahtinen E, Leppo K (eds.) Health in all policies: Prospects and potentials. Finland: Ministry of Social Affairs and Health, 2006. 5. Hunter D. Zorg voor gezondheid vergt meer dan gezondheidszorg: de noodzaak van een nieuw paradigma’. NIGZ, 2007. 6. Gezond in de Stad. Kadernota openbare gezondheidszorg 2007-2010. Rotterdam: GGD Rotterdam-Rijnmond, januari 2007 7. Volksgezondheid en preventie. De visie van de KNMG. Utrecht: juni 2007, KNMG. 8. Landelijke Huisartsen Vereniging. Standpunt ‘Preventie’. www. lhv.nl 9. Nederlandse Public Health Federatie. Brief aan de Minister van Volksgezondheid, Welzijn en Sport, over diens kaderbrief en brede preventievisie. 19 november 2007. 10. Lo Fo Wong S. The doctor and the woman who "fell down the stairs". Family doctor's role in recognising and responding to intimate partner abuse. Dissertation. Nijmegen, 2006 11. Godelieve van Heteren in G 6/07:13 12. David Hunter in G 6/07:11 13. Jansen M. Mind the gap: Collaboration between practice, policy and research in local public health. Dissertation. Maastricht: Universitaire Pers Maastricht, 2007
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HOW CAN POLITICS AND PUBLIC HEALTH LEARN FROM EACH OTHER? -- the asbestos saga --
Lex Burdorf
INTRODUCTION The gap All researchers in public health share the experience that their scientific work is not always appreciated by policy makers and politicians. We all have interesting stories on how scientific progress and the subsequent benefits for society were stalled by political decision-making. Image this familiar scene. You have just reported the latest findings of your study to participants at a conference and have responded spendidly to some enquiring questions. Next on the programme is the inevitable panel discussion. The politician on duty remarks that your results seem to underpin their new policy document and, subsequently, he or she explains the new government guidelines which completely contradict the implications of your study. In such situations, at best we humbly mutter an excuse and quietly find the emergency exit, shaking our head on this complete incomprehension. Should we be more straightforward and clearly express what is on our minds? Take this lesson from the famous Dutch football coach Louis van Gaal, expressing his contempt for lack of understanding: “Am I really that smart or are you so stupid ?” (“Ben ik nou zo slim of ben jij nu zo dom”) – in response to a journalist on a postmatch press conference in 1996. In this short essay I would like to explore the essence of the seemingly deranged communication between politicians and public health professionals, steeply based in my personal experiences with the asbestos saga in the past 28 years.
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THE ASBESTOS SAGA The public health paradigm Every year during the introductory lectures on public health research I duly teach our students that the public health paradigm has three core elements: (1) Causes of disease can be found in the environment and be removed by prevention, (2) Collective action, on the basis of solidarity, is the most effective way of improving population health, and (3) Quantitative methods are the best for finding causes and studying intervention effects. These core elements are derived from two well-established definitions of public health. Acheson states that public health is “the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society”. [1] Interestingly, he includes both science and art in his definition, as a reflection of his opinion on the public health function of health services. Beaglehole and colleagues opt for a more policy-oriented approach by describing public health work as the “collective action for sustained population-wide health improvement”.[2,3] Both definitions emphasize that public health must focus on population health and the physical and social environmental determinants of health. Reliance in science My first experience with the asbestos problem stems from answering a question from a workers’ committee of the largest asbestos-cement factory in The Netherlands around 1979. The committee wanted to know the health risks of existing working conditions in their factory. I took part in conducting a basic risk assessment with the final conclusion that the current exposure levels would result in clearly increased risks for the occurrence of asbestos-related diseases, most notably mesothelioma and lung cancer. After several meetings with the workers’ committee, on their request, we decided to conduct a small survey to establish whether cases of mesothelioma had already occurred in the workforce. A typical public health approach: (1) the cause of disease is in the environment, (2) the most effective intervention is reduction/elimination of exposure, and (3) a quantitative study should convince the company management and the Labour Inspectorate that preventive actions should be taken. The case-control study was performed and showed that at least 2 cases of mesothelioma had occurred among the workforce. In order to ensure that no one would miss the results of our study, we arranged a press conference in the local village of the factory (Goor) with live broadcast in a prime-time news show in 1984. I had a huge reliance in science and 38
Figure 7 Asbestos workers in the Netherlands, around 1960
was convinced that preventive measures at local and national level would follow soon. What happened next was not what I had envisaged. There was no reaction from politicians (“We do not make regulations for 2 cases” was an interesting statement a few years later), the policy makers from the Labour Inspectorate argued that there already was on ongoing collaborative action to improve the working conditions, and the company management threatened to sue us. The head of the Department of Health Sciences in Wageningen University, the late professor Klaas Biersteker, had a good laugh about this and explained that academic freedom also extended to students in his programme. First lessons learned The famous phrase of another Dutch football coach Johan Cruijff turned out to be true: “Every disadvantage has its advantage”. (Elk nadeel heb zijn voordeel.) The study was well-done, even published as a short report in a Dutch journal, but the message did not appeal to politicians. With the “collective action for sustained population-wide health improvement” in mind, we conveyed our message about the dangers of asbestos exposure through many lectures to union members, safety engineers in 39
companies, and decision makers in large companies. In 1989 we wrote an article in a Dutch magazine with the headline: 600 deaths every year.[4] A ban on asbestos could save 600 lives each year, which must have been one of the most powerful interventions available in public health at the time. The scientific logic is not on the politician’s mind Again, what happened was not according to plan. A commercial network phoned and asked about the annual number of victims. I proudly stated “certainly 600”, but they turned it down on the argument that it did not reach 1,000 per year. The Labour Inspectorate was basically convinced that it was a problem of the past and that the increasingly stringent legislation would prevent future casualties. Letters to two political parties did not trigger a response. Next, imagine the aforementioned familiar scene. I presented the evidence of 600 deaths due to asbestos each year at a national conference. The inevitable panel discussion hosted a politician, who vehemently attacked me that this was all due to working conditions 30 years ago, current legislation was sufficiently strict to work safely with asbestos, and, moreover, I was endangering preciously needed jobs in industry. The figure of 600 was just a number and everyone knew that epidemiology is just a number crunching game. Not-so-silent victims It is time to turn to another lesson from Johan Cruijff: “You will only start seeing it, if you understand it” (Je gaat het pas zien als je het door hebt.) The 600 asbestos-related deaths were based on national statistics and, thus, remained anonymous. Victims without a voice are never noticed in politics, an important reason why primary prevention is hard to sell. The great break-through started with a compensation claim law suit in 1990, of three widows who had lost their husbands due to mesothelioma while working in the asbestos-cement factory in Goor. These three women made headlines in local newspapers. They argued perfectly well why a ban on asbestos was essential to safeguard workers’ health! Their lawyer arranged a meeting between victims, politicians, and scientists. Political support for a complete ban on asbestos was quickly established. A few years later, the Committee of Asbestos Victims was officially founded. This Committee quickly became a powerful pressure group and in their yearly meetings they confronted politicians and scientists with the human face of the problem; workers with mesothelioma presented their stories and argued their case. In 2000 a national compensation scheme came into effect, following the advice of a parliamentary working group. Under this scheme, victims with mesothelioma will receive a financial 40
settlement as compensation. The forecast that the historical asbestos use in The Netherlands would ultimately result in a death toll of 19,000 persons over the period 1969-2030 only played a minor role in these developments.[5] Influencing the research agenda and political decisions Around 2000, during a meeting with the Committee of Asbestos Victims, it became clear that mesothelioma cases also occurred as a result of environmental pollution around the asbestos-cement factory. Public health researchers had already warned about the risks of environmental exposure to asbestos from 1968 onwards.[6] Unfortunately, funding agencies and the government were not interested to support studies in this area. With the help from a lawyer, we gained access to 810 requests for compensation and identified 5 cases of pleural mesothelioma among women in the direct vicinity of the factory, whereas the expected number was about 0.46. Based on this 10-fold increase in risk, we advised to conduct a systematic study on asbestos exposure among all cases of pleural mesothelioma in the city Hof van Twente from 1990 onwards.[7] The publication in the Nederlands Tijdschrift voor Geneeskunde in 2004 led to questions in parliament. Do politicians read scientific journals, you may wonder. The questions were carefully timed in collaboration among victims, scientists, and politicians. Within a few months the Ministry of Health commissioned a study along the lines of our advice. The results of the study were submitted in two reports to the government in September 2005. It was very quiet for a couple of months, but in November 2005 we were invited to present the study results at a press conference in the city Hof van Twente. It proved to be worth waiting. The study results were accepted without any discussion. National and local politicians expressed their sincere sorrow to the victims and pledged for immediate action. The responsible Secretary of State announced in Parliament, exactly at the time of the press conference, that the Ministry of Health would make available €70 million for a complete cleanup of the polluted area. In addition, financial compensation for victims would be arranged as soon as possible.
FINAL LESSONS LEARNED For nearly three decades my research on asbestos has been conducted in close collaboration with important stakeholders, most notably the victims with asbestos-related diseases. Time and again the interaction with politicians surprised me. The most powerful impact was made by the values and beliefs of men and women suffering from asbestos-related 41
diseases, and science at best only played a supporting role in creating and implementing solutions. The logical thinking in science does not seem to interact well with political processes. The social scientist and anthropologist Gregory Bateson once defined information as "a difference that makes a difference". He proposed logical levels of thinking for understanding change from an individual, social, and organizational point of view. He reasoned that identity, mission and values have much more impact than environmental factors and behaviour.[8] Interestingly, public health researchers tend to focus primarily on the physical and social environment when they present evidence in support of specific actions that need to be taken. Would it not be better to discuss required changes in societal values or mission statements? In a recent editorial on the need for evidence-based medicine the author acknowledges that “in the end values will always be more influential than evidence, and the tension between the two should be regarded as the very stuff of the relationship between expert and politician.”[9] With this in mind public health should reconsider its origins. Acheson’s definition talks about science and art. The founding fathers and mothers of public health often combined science and art in person through an active engagement with social and political processess. In the past decades the pendulum has swung strongly to science. In recent years interest in the societal impact of research has increased, and this puts more emphasis on the art of public health. Is it already time to argue that research evaluation exercises should count ‘one collaborative activity between a scientist and a politician’ as equal to ‘one peerreviewed publication in a journal with a good impact factor’? References 1. Acheson D. Committee of Inquiry into the future development of the Public Health Function. Public Health in England. London: HMSO, 1988. 2. Beaglehole R, Bonita R. Public Health at the Crossroads: Achievements and Prospects. Cambridge: Cambridge University Press, 2nd ed. 2004 3. Beaglehole R, Bonita R, Horton R, Adams O, McKee M. Public health in the new era: improving health through collective action. Lancet 2004;363:2084-6. 4. Burdorf A, Klaver J, Swuste P. Asbest: handig, onverwoestbaar en dodelijk. Intermediair 1989;25(32):37-43. [Asbestos: convenient, indestructible, and deathly] 5. Swuste PHJJ, Burdorf A, Ruers B. Asbestos, asbestos diseases, and compensation claims in The Netherlands. Int J Occup Environ Health 2004;10:15965. 6. Zielhuis R. Asbest en mesothelioom. Ned T Geneesk 1968;112:773.[Asbestos and mesothelioma] 7. Burdorf A, Dahhan M, Swuste PHJJ. Milieublootstelling aan asbest en het optreden van pleura mesothelioom. Ned Tijdschr Geneesk 2004;148:172731.[Environmental pollution to asbestos and the occurrence of pleural mesothelioma]
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8. Bateson G. Cited on website http://en.wikipedia.org/wiki/Gregory_Bateson#_note-4 (accessed January 2, 2008) 9. Muir Gray JA. Evidence based policy making is about taking decisions based on evidence and the needs and values of the population. BMJ 2004;329:988-9.
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