A Systematic Review of Key Issues in Public Health (I)
In my review of the book on goodreads I did not have many nice things to say about this book, but I do note that the book had some interesting data. I’ll save those for another post – in this post I’ll provide some of the reasons why the book got a one star rating. Given the format of the book I thought I should clarify a bit what I didn’t like about it, because both the title and actually also the basic structure maked the book seem quite promising; they cover a lot of review articles and a lot of studies, so how could I possibly dislike a book like that? Well…
The main issue: If I thought the Psychology of Lifestyle book was bad in terms of implicit political assumptions etc., this book takes this to a whole different level. Outright bans and severe restrictions on behaviours harming health are repeatedly described as either cost-effective or ‘best buys’, and many chapters don’t even touch upon potential problems associated with such policies, making you start wondering along the way why policies such as national bans on alcohol and tobacco and special police forces armed with automatic weapons coming to your house during the night and throwing you in jail if you’re found smoking a cigarette aren’t already implemented worldwide, if the research looks that way. The political agenda here seems so apparent in many chapters that you start questioning the reporting because you figure these people would not be above lying to you to get the sort of policies they’d like. Faulty assumptions throughout the coverage don’t help – as a rule you don’t get significant health effects by simply providing information about healthy behaviours and behavioural risk factors to the population; we know this from a large number of studies – and I know this because I just read a book about this research – so the fact that some authors assume such interventions to be ‘cost-effective’, and that they can point to one very old example where there does seem to have been some measurable effects, does not convince me. Some of the authors point to interventions involving primary care physicians lecturing people about healthy lifestyle behaviours being cost effective, without at all going into the many issues related to even evaluating the long-run health effects of such interventions. That effects might not persist over time is not the impression you get from this kind of coverage:
“The evidence suggests that counseling by physicians to reduce intake of total fat, saturated fat intake, and daily salt, and to increase fruit and vegetable intake, is very cost-effective, leading to dietary changes, improved weight control, and increased physical activity [64–69].” (p. 55).
Compare with for example this quote from Thirlaway and Upton:
“Hundreds of interventions to combat the obesity epidemic are currently being introduced worldwide, but there are significant gaps in the evidence base for such interventions and few been evaluated in a way that enables any definitive conclusions to be drawn about their effectiveness. Those that have shown an impact are limited to easily controlled settings and it remains unclear how promising small-scale initiatives would be scaled up for whole population impact”.
What people compare when doing the CEAs in the book is occasionally/often unclear, which tends to make that sort of reporting close to worthless. I had the impression in some parts of the coverage that what was driving cost-effectiveness in some of the studies was a combination of large health impacts of disease + assumed but unproven/speculative health impacts of the interventions; an impression probably partly a result of the intervention study coverage provided in Thirlaway & Upton.
‘Implicit assumptions’ and more or less overtly politicizing comments along the way spoiled the reading experience. Below I have added some examples of sentences I for various reasons did not like:
“Several countries have explored fiscal measures such as increased taxation on foods that should be consumed in lower quantities and decreased taxation, price subsidies or production incentives for foods that are encouraged.” (‘foods that should be consumed…’).
“Restriction of alcohol drinking to the limits indicated by the European Code Against Cancer  (20 g/day for men and 10 g/day for women) would avoid about 90 % of alcohol-related cancers and cancer deaths in men and over 50 % of cancers in women, i.e. about 330/360,000 cancer cases and about 200/220,000 cancer deaths. Avoidance or moderation of alcohol consumption to 2 drinks/day in men and 1 drink/day in women is therefore a global public health priority” [The idea that men might not want to avoid 90% of alcohol-related cancers doesn’t seem to cross the minds of these authors – they want them to not get cancer, and they’re going to get their way one way or the other, dammit!]
“Nowadays, obesity is the most frequently encountered metabolic disease” [Disease? Disease???]
“T2D is the most common type of diabetes, representing 90 % of cases worldwide and it is named non-insulin-dependent diabetes mellitus (NIDDM)” [My comment in the margin: “No, it’s actually not. No longer. Because this is a terrible name. A majority of diabetics on insulin treatment are type 2 diabetics.” (see also my comments in the last paragraph here if you’re curious to know more about this topic)]
“The difficulty of communicating is, however, exactly the major obstacle in this communion of responsibility. In this regard, we shall analyze the dynamics of interpersonal communication based on the scheme proposed by Slama-Cazacu . According to this model the elements of a communicative act are: (1) the transmitter, who produces the message, (2) the message conveyed according to the rules provided by code; (3) the code according to which the message is produced; (4) the transmission channel; (5) the context in which the message is found and to which it refers; and (6) the receiver” [To be frank, the chapter from which this quote is taken – Some Ethical Reflections in Public Health – had almost nothing but problematic sentences, despite actually addressing a few issues I’d had with the coverage elsewhere in the publication. I thought the quote illustrated how rambling and besides-the-point that coverage was; recall that this is a chapter about ethics. The quote was used to provide context so that you’d understand e.g. that people sometimes don’t understand health messages. Incidentally you should not be fooled by the quote into assuming that the author actually covered any data about how sensitive people are to health data in this coverage (how information impacts behaviour). She of course did not.]
“The distal risk factors of ethnic groups thus explain why a certain proximal risk factor is unevenly distributed across ethnic groups. If, for example, a certain ethnic minority group has an increased prevalence of smoking, this may be due to the fact that the group is exposed to discrimination in the host country (relational), or to specific sociocultural values characteristic for that group (attributional).” [My comment in the margin: “Discrimination => smoking? Seriously? Stop being stupid.” I was close to losing my patience at this point…]
“metabolic control is poor among migrant groups with diabetes, and HbA1c in migrants is generally higher than in the local-born population [3, 32]. These findings suggest shortfalls in diabetes health care among migrant populations.” [“Or some of the immigrants are stupid and irresponsible.” As mentioned, I was losing patience fast… (In the margin the words ‘some of’ were of course not included, but I live in a wonderful country where omitting such qualifiers in texts like this one run you the risk of getting thrown in jail for ‘racism’..)]
“For European health care contexts, empirical research on inequalities in healthcare outcomes is scarce. For some diseases or care contexts, ethnic inequalities in outcomes, attributable to deficient care, have been shown.” [Stuff like this was also part of the reason for the outburst above – I got really annoyed in this chapter, because the author repeatedly seemed to assume/implicitly assert that anything less than equal coverage for all individuals living in a country was a state that was really morally unjustifiable – later talk about ‘diversity-responsive care’ did not help. I don’t understand how anyone would consider it to be fair that a guy getting sick after paying taxes into the cost-sharing mechanism financing his care for 30 years do not get better health care coverage than some poor immigrant who just arrived yesterday and haven’t paid anything into the scheme, but anyway this is politics and so I shouldn’t bother.]
“In developing countries, the prevalence of some form of depression among urban adults ranges from 12 to 51 %” [No, it probably doesn’t…]
“Of course, in a millennium in which next to the advancement of health technologies (digital, with the development of nanotechnology; social and cultural, with the emergence of new values that should be conjugated with the old; scientific and medical, through imaging and the study of genomics, proteomics, and metabolomics; etc.) there is a global crisis of the world economy, it is fundamental to strengthen and use the assets of individual and community resilience (most definitions of resilience refer to notions—derived from physics—of rebound, or bouncing back, from deformation or distress), also because action to improve community health requires the coordination and the cooperation of decision makers in many sectors responsible for shaping wider determinants, and also because the traditional management of policy may be ineffective to address the problems of the “future cities” and requires an institutional change, given the discrepancy that can exist between technological innovation, scientific evolution, and adaptive flexibility of governance systems.” [This was around the point where I decided that no matter what happened in the last couple of chapters, this book is going to get one star]
“The National Institute for Public Health and the Environment was committed to analyze opportunities to address health inequalities through the HiAP strategy. On the basis of data derived from the document analysis, 38 out of 153 policy resolutions were identified to have a potential impact on determinants of health inequalities. Resolutions often consisted of a combination of policy measures, projects, and programs and were mostly released by the Ministry of Housing, Communities, and Integration and by the Ministry of the Education, Culture, and Science. Fifteen resolutions were on the enhancement of socioeconomic position; 4 on striving participation of people with health problems; 19 on improving living and working environment and lifestyle; and 4 on accessibility and quality of care. Interestingly, only 11 were inter-sectoral collaboration between the Ministry of Health and other ministries. This aspect allows us to conclude that even though HiAP is officially recognized as a strategic approach to be followed in setting policies and programs, further efforts are needed at European and global levels in order to implement in a practical manner.” [I’m pretty sure if this stuff had not been located in the last chapter of the book, I’d never have finished the book.]
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