Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK. E-mail: mary.shaw{at}bristol.ac.uk
As academics we focus very much on epidemiological matters discussed in the forum of a fairly narrow range of published literature, yet the real stuff of epidemiology (and its contribution to public health medicine) is constantly taking place in the wider world around us. This editorial was written at the beginning of the calendar year, a time when, once again, magazines, newspapers and television overflow with advice for improving health and well-being. Each January we are repeatedly bombarded with messages to quit smoking, lose weight and do more exercise. Start the new year righttreat your body to a tune-up! Indeed, health and well-being tips are now a perennial feature of an approach to health which in the West has become overwhelmingly individualistic, and increasingly consumeristhealth (and health care) is something that the individual purchases.
Of course, if the public did follow this advice the impact on public health, not to say the public purse, would be huge. Imagine the effect if smokers really did kick the habit. In reality behaviour change is very difficult to achievethe evidence of the effectiveness of even the best-crafted mass media campaigns aimed at reducing smoking, for example, is not strong.1 Similar difficulties are faced when exercise is the issue. The promotion of physical activity has been argued to be the best option for public health, at least in terms of coronary heart disease.2 In England, the majority of people are not physically active;3 the World Health Organization (WHO) estimates that 60% of the world's population is not physically active enough to gain health benefits.4 Systematic reviews5,6 have found that public health interventions to increase levels of physical activity often have no overall effect. At best they result in increased levels of activity in only a small proportion of the population that are for the most part only maintained in the short-term. In the mid-1980s WHO identified settings (workplaces, neighbourhoods, schools, etc.) as vehicles for health promotion, yet this signalled only a minor shift away from individualistic strategies. The majority of interventions to improve and promote population health continue to focus on individual behaviour change. Even when we know the effect is minimal, we still cling to the individualistic model.
Such findings, and failures, surely ought to encourage us to think outside the box, to look beyond the individual. Most epidemiological studies contain clues, if not evidence, of the effect of broader-level factors impacting on health where interventions could be aimed. Yet changing the errant behaviour of individuals remains a favourite with even those who are the most well-informed and well-placed to bring about other forms of change. In 1999 for example, the Chief Medical Officer for England issued advice on his top ten tips for better health (Figure 1). Despite a raft of reports and policies (www.doh.gov.uk/healthinequalities) which acknowledge the role of socioeconomic and structural factors in producing health inequalities, these tips were released without reference to such broader issues. Responsibility was thus placed firmly upon the individual. The Townsend Centre for International Poverty Research at the University of Bristol responded to these tips with an albeit tongue-in-cheek list of alternatives which (re)place the emphasis and responsibility for change firmly beyond the individual, instead focusing on structural-level issues such as the distribution of income, the provision of welfare benefits and housing conditions.
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Clearly there are some areas where a structural approach to public health has potential, or is at least less problematic than other optionsregulating the industrial output of factories is certainly an easier target than tackling the mighty power of the tobacco companies, or restricting the smokers' freedom to choose to smoke. Accidents and injuries, a theme in this issue of the International Journal of Epidemiology, is one such area where structural and legislative approaches might have most promise. Accidents are not randomly distributed events, in either lay or statistical terms. Instead they are patterned by social, cultural and environmental factorsthey even reflect the way we organize time, varying by day of the week and time of day (the patterning of road traffic accidents among children reflecting school timetables are a prime example of this16). Accidents are what Durkheim would term social facts,17 existing sui generis over and above individuals and being the product of the way that society and the environment are organized (you cannot die in a road traffic accident unless you live in a society with cars and roads; you cannot shoot yourself or someone else if you do not have a gun). Half a century after Morris18 highlighted the relationship between the rate of accidents in coal mines with the number of workers in a mine as a social-epidemiological lead (the greater degree of camaraderie in smaller mines protecting the workers in the event of danger) a British Medical Journal editorial called for the banning of the word accident.19 In that editorial Davis and Pless argue that the word accident is inappropriate for events that are both predictable and preventable.
A prime example of such predictable and preventable events, and of the public health potential of a legislative change, is the current situation with firearms in the US. In 1994 in the US there were 38 505 firearm-related deathsover 17 800 firearm-related homicides, over 18 700 firearm-related suicides and over 1300 unintentional deaths due to firearms (accidents if you prefer the more familiar, less attributive, vocabulary).20 In 2001 the Surgeon General in the US released a report on Youth Violence,21 which is seen as an epidemic deserving of high priority intervention, prompted at least in part by recent school shootings. The report lists 27 specific youth violence intervention programmes, including functional family therapy, multisystemic therapy and life skills training. The report notes that gun buy-back schemes, firearm training and mandatory gun ownership (approaches which were expected to deter gun violence by increasing the number of private citizens who were trained to use guns properly and who owned firearms for protection) have been found to be ineffective in reducing firearm-related crimes. There is no mention of simply restricting the availability of firearms through legislation. Follow this social-epidemiological lead: the rate of homicides due to guns is 175 times higher in the US than in Britain; 48% of Americans compared to 4.7% of British households have guns.22 Gun control has been found to be an effective intervention for reducing both homicide and suicide rates.23,24 Yet in the US, where every individual has the right to bear arms but not everyone has the right to health care, a legislative approach to this problem is clearly seen as so politically objectionable that it is not even raised as a possibility.
As professionals concerned with public health, how often do we reflect upon the bigger picture, let alone do anything about it? All too often we forget that behaviours and decisions at a number of levelsfrom the individual, to the organizational to the politicalaffect the health of populations. Are we losing our way, missing social-epidemiological leads, and foregoing opportunities by not considering the role of the legislature in improving public health?
References
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2 Morris JN. Exercise in the prevention of coronary heart disease: today's best buy in public health. Med Sci Sports Exerc 1994;26:80714.[ISI][Medline]
3 Department of Health Physical Activity Task Force. More People, More Active, More Often. Physical Activity in England. London: The Stationery Office, 1995.
4 World Health Organization. Physical Activity Factsheet. 2002. http://www.who.int/hpr/physactiv/physactivfactsheet.pdf
5 Riddoch CJ, Puig-Ribera A, Cooper A. The Effectiveness of Physical Activity Promotion Schemes in Primary Care: A Systematic Review. London: Health Education Authority, 1998.
6
Lawlor DA, Hanratty B. The effect of physical activity advice given in routine primary care consultations: a systematic review. J Public Health Med 2001;23:21926.
7 Shaw M. Try out alternative slant on the Top 10 tips for better health. Health Service Journal, 27 September 2001.
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11
Hawton K, Townsend E, Deeks J et al. Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study. BMJ 2001;322:17.
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Davey Smith G, Ebrahim, S, Frankel S. How policy informs the evidence. BMJ 2001;322:18485.
16 Department of Transport. Children and Roads: A Safer Way. London: Her Majesty's Stationery Office, 1990.
17 Durkheim E. Suicide: A Study in Sociology. London: Routledge, 1999 (first published 1897).
18 Morris JN. Uses of Epidemiology. Edinburgh and London: E&S Livingstone Ltd, 1957.
19
Davis RM, Pless B. BMJ bans accidents: Accidents are not unpredictable. BMJ 2001;322:132021.
20 National Center for Injury Prevention and Control. National Summary of Injury Mortality Data, 19871994. Atlanta, GA: Centers for Disease Control and Prevention, November 1996.
21 Department of Health and Human Services. Youth Violence: A Report of the Surgeon General. Washington DC: Department of Health and Human Services, 2001.
22
Chapman S. Elimination of firearms. BMJ 1997;315:101920.
23 Killias M. Gun ownership, suicide and homicide: an international perspective. In: del Frate A, Zvekic U, van Dijk JJM (eds). Understanding Crime and Experiences of Crime and Crime Control. United Nations Interregional Crime and Justice Research Institute, Publication No. 49. Rome: UNICRI, 1993.
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