Interesting Talk by Prof Julian Le Grand
Should government be a friend or a nanny state vis-à-vis individual behaviour?
— Dr R Neerunjun Gopee
Julien Le Grand is the Richard Titmuss Professor of Social Policy at the London School of Economics. He is an Honorary Fellow of the Faculty of Public Health Medicine, and at one time was the adviser of British Prime Minister Tony Blair on health matters.
Health is ever an issue of great importance and concern, both to individuals and to governments. Although there is no ideal health system, implying that every country has to make up its own, still there are certain core social, health economics, and organizational/management considerations and principles of undisputed validity that can guide the elaboration of an appropriate health system, making allowance at the same time for the country-specific cultural context. A main limiting factor is the amount of money that a government is prepared to commit to the health service, and all countries face this dilemma.
It is an undeniable fact that healthcare costs are rising everywhere, and funding for health ranges from a highest nearly 16% of the GDP in the US, through an average of 10% in European countries, to the lowest of around 2% and under of GDP in the Sub-Saharan region. In Mauritius this figure is 3-4%. Given this variation, it is no surprise that there are large health inequalities in the world, not only between the countries with high, middle or low income, but within the countries themselves to match, as it were, their social inequalities.
Health sector reform can be a make or break politically speaking: only a few days ago, at a mammoth meeting of the Royal College of Nursing in the UK, nurses voted to reject the healthcare reforms in the National Health System proposed by the government, which involves massive cuts as well as changes in the modalities of financing of the services. Doctors there also have come down heavily on these reforms, and there is an indication that the government may be amenable to revisiting some aspects.
In the US, healthcare reform was a major plank on which President Obama fought during his campaign for the presidency. He has managed with great difficulty and much opposition from the Republican Party to secure a vote in favour of the reform, but there is a long way to go before effective implementation takes place – this is crucial in the US, where nearly 50 million Americans do not have health insurance, and one of the most important aims of the reform is to provide health insurance coverage to this large group.
During his lecture at the Harilal Vaghjee Hall on Wednesday afternoon, Professor Le Grand showed a pie chart about the social determinants of health which revealed some interesting figures about the relative contributions to health of: genetics – 30%; behaviour – 40%; environment – 15 %; healthcare a meagerly 10%, and environment the remaining 5%. He did not elaborate on how he arrived at these figures, but the thrust of his talk was on the ways and means that governments could use to influence individual behaviour so as to achieve better health outcomes without, however, appearing to be coercive.
In other words, such interventions on the part of government should interfere minimally with individual freedoms. This was reflected in the title of his lecture about whether government should be a friend or a nanny state vis-à-vis individual behaviour? The assumption, or at least one such, was that individuals do not live up enough to their responsibilities for their own health.
Given behaviour’s larger contribution to health, according to the figures of Prof Le Grand, an emphasis on changing it seems an obvious starting point to do so. He quoted John Stuart Mill’s ‘Harm Principle’ when commenting on this approach, ‘That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.’
In matters of health, this ‘harm’ has to be taken up by government in the form of health costs, and so it is that government may intervene to prohibit (smoking) or facilitate (exercise) certain types of behaviours through various measures such as taxes (on tobacco), subsidies (food items), opt-in and opt-out (blood/organ donation), regulations and education among the main and better-known ones.
Of course, the effects will not be immediately apparent because overnight change in behaviour is a utopian expectation (for example, shortened queues at fast-food outlets – or ‘dalpuri lines’! ), and one must take a medium to long term view as far as outcomes are concerned – meaning years rather than weeks or months, as some ignoramuses believe. Incidentally, may I remind readers that an expert in nutrition from the World Health Organisation has observed that dalpuris are a nutritious and balanced food.
It is well known to practically everyone that the major causes of ill-health nowadays are excessive alcohol consumption, tobacco, lack of physical exercise, poor quality food and environmental pollution (of water, air, residues and other chemicals in vegetables) and chemicals or contaminants in processed foods. It stands to reason that to be in good health people must not smoke, be moderate in alcohol consumption, have proper nutrition and engage in sufficient physical activity.
The example in modern times which demonstrated dramatically that changing behaviours could improve health outcomes is that of the district of North Karelia in Finland. It had the highest rates of heart disease and deaths caused by the condition in the country, and community-led efforts under the direction of one of the foremost Public Health specialists in the world, Professor Jaakko Tuomelihto, were successful in reducing those rates drastically, by almost 50% — and over the years, this improvement has been maintained, with a decrease in the prevalence of other non-communicable diseases as well. For more details if interested, one may simply google ‘North Karelia Project.’ It is to be noted that Prof Tuomelihto is a friend of Mauritius, having been associated with the country’s NCD surveys since the first one in 1987, and currently he is preparing a Master Plan for Primary Health Care for the country.
As I have written in an earlier article, ‘The amazing thing about humans is that, in spite of knowing that something can cause them harm, they will still pursue it. Or, knowing that something can do them good, they will find a thousand and one pretexts to avoid it. In medical practice we see this daily. For example, in relation to cigarettes, alcohol, eating habits, and lifestyle in general – such as exercising, walking instead of taking the car for short trips, pursuing relationships/activities which impact negatively on one’s bodily, mental and emotional health or on the family, and so on and so forth.’
One important message that comes from the presentation of Prof Le Grand is that there is ample room for intelligent debate, informed by disciplines such as economics, social policy analysis, sociology and psychology amongst the main ones, on issues relating to the health of the country at large. This must be carried out seriously – to take but the example of Prof Le Grand himself – and in a structured manner, and there must be an established mechanism or structure for channelling such views into official perspectives and decision-making processes for the benefit of the whole population.
A beginning has been made in this direction by the Mauritius Research Council, which recently organized a workshop to present the results of a survey on a ‘Needs Assessment for Neurological Rehabilitation Services in Mauritius.’ This was carried out over a period of several months by a young specialist in social policy analysis recruited by the MRC, with the involvement of two diaspora Mauritians working abroad in the field, one a Consultant in the UK and the other a Professor at Harvard University. We need more of this kind of input if we want our health service to come up to international standards, and since there has been a beginning, it would be worthwhile to encourage more of such initiatives to explore more aspects of our health service.
We must thank Prof Le Grand for helping to open avenues of fresh thinking about health services in general and ours in particular.