Last updated: 23 December 1998
It makes little sense to expect individuals to behave differently from
their peers; it is more appropriate to seek a general change in behavioural
norms and in the circumstances which facilitate their adoption.
Measures to improve public health, relating as they do to such obvious
and mundane matters as housing, smoking, and food, may lack the glamour
of high-technology medicine, but what they lack in excitement they gain
in their potential impact on health, precisely because they deal with the
major causes of common disease and disabilities.
The current social, occupational, and national inequalities in health
will not be much influenced by health education, for they reflect the way
that societies are organized. We already know what is desirable; the obstacles
to its achievement, which prevent the majority from having what some already
enjoy, are substantially economic, industrial, and political.
In preventive medicine the prospect of personal benefits to health provides
only a weak motivation to accept a change, since it is neither immediate
nor substantial, and an individual's health next year is likely to be much
the same, regardless whether that person accepts or rejects the proferred
The high-risk preventive strategy ... is a targeted rescue operation
for vulnerable individuals.
If a small amount of alcohol slightly impairs a driver's judgement,
then the large number of drivers who have had one or two drinks would collectively
incur a large excess of accidents, even though none of them individually
had an obvious problem, but current policy assumes that this is not the
A radical approach aims to remove the underlying impediments to healthier
behaviour, or to control the adverse pressures. The first or medical approach
is important, but only the social and political approach confronts the
The problems of sick minorities are considered as though their existence
were independent of the rest of society. Alcoholics, drug addicts, rioters,
vandals and criminals, the obese, the handicapped, the mentally ill, the
poor, the homeless, the unemployed, and the hungry, whether close at hand
or in the Third World - all these are seen as problem groups, different
and separate from the rest of their society.
Mass behavioural changes can be related to changes in opportunity (bicycles
instead of walking, then cars instead of bicycles), in price (turkey, once
the food of aristocrats, now the ordinary man's Christmas dinner), in convenience
(refrigerators favour soft margarine rather than butter, and food can now
be stored without salting), in fashion (modern Western disapproval of plumpness
in women), and in pressures from opinion leaders and health educators (smoking
in developed countries) opposed by those from manufacturers and advertises
(smoking in developing countries).
... socio-economic deprivation includes a whole constellation of closely
interrelated factors, such as lack of money, overcrowded and substandard
housing, living in a poor locality, worse education, unsatisfying work
or actual unemployment, and reduced social approval and self-esteem. In
turn this constellation of deprivations leads to a wide range of unhealthy
behaviours, including smoking, alcohol excess, poor diet, lack of exercise,
and a generally lower regard for future health.
In a democracy the ultimate responsibility for decisions on health policy
should lie with the public. At present that does not happen.
The primary determinants of disease are mainly economic and social,
and therefore its remedies must also be economic and social. Medicine and
politics cannot and should not be kept apart.
... political effort should be focused on three broader components of
deprivation, each of which profoundly influences health and where some
progress would be possible even in the face of economic inequalities: these
are education, housing, and unemployment.
Much can be done by individuals themselves to improve their own health
prospects, but whether or not they will actually take such action depends
substantially on economic and social structures for which governments are
The so-called free market system, which for a time now dominates political
and economic thinking, implies freedom for wealth-generators at the price
of a severe curtailment of freedom for the rest of the population.
To enable people to make and to implement healthy choices requires information
and facilities which must be centrally funded and provided.
In public and governmental perception the harm from polluted air tends
to be exaggerated, whereas that from poverty is underestimated.
... the fact that in many countries smoking has become much less prevalent
does not make it any less risky to the individual smoker but it does reduce
the potential benefit from an anti-smoking campaign.
People are generally motivated only by the prospect of benefit which
is visible, early, and likely. Health benefits rarely meet these criteria;
they may be real, but they are likely to be delayed and to come to only
a few of those who seek them.
... a preventive measure that brings large benefits to the community
offers little to each participating individual.
A population strategy of prevention is necessary where risk is widely
diffused through the whole population.
... high-risk strategy, in which efforts are focused on those individuals
who are judged mostly likely to develop disease.
The scale and pattern of disease reflect the way that people live and
their social, economic, and environmental circumstances, and all of these
can change quickly.
The essential determinants of the health of society are thus to be found
in its mass characteristics: the deviant minority can only be understood
when seen in its societal context, and effective prevention requires changes
which involve the population as a whole.
... the idea of a sharp distinction between health and disease is a
medical artefact for which nature, if consulted, provides no support.
... the prevention of deaths is only likely to involve net economic
advantage if it applies to children or young adults, and beyond the age
of about 50 the economic outcome is increasingly negative as applied to
preventive measures which extend survival.
... a risk which has not materialized within the individual's own experience
is unlikely to be regarded seriously.
... society is not merely a collection of individuals but is also a
collectivity, and the behaviour and health of its individual members are
profoundly influenced by its collective characteristics and social norms.
Social norms rigidly constrain how we live, and individuals who transgress
the limits can expect trouble. We may think that our personal life-style
represents our own free choice, but that belief is often mistaken. It is
hard to be a non-smoker in a smoking milieu, or vice versa, and it may
be impossible to eat very differently from one's family and associates.
Social norms set rigid limits on diversity, and those wishing to persuade
minorities to be different from the majority would do well to remember
... risk factors predict disease but they do not necessarily cause disease
or predict benefit from an intervention: low income is associated with
more illness, but health may not be improved by winning a large sum of
money on the football pools.
... moderate and achievable change by the population as a whole might
greatly reduce the number of people with conspicuous problems. Conversely,
it is hard to find any examples where deviation has been suppressed and
everyone conforms to the 'happy mean'. The abolition of deviance, whilst
leaving the population as a whole unchanged, seems not to occur: the forces
for diversity prevent it.
... the burden of ill health comes more from the many who are exposed
to a low inconspicuous risk than from the few who face an obvious problem.
This sets a limit to the effectiveness of an individual (high-risk) approach
... a large number of people exposed to a small risk may generate many
more cases than a small number exposed to a high risk.
In summary, the purpose of risk assessment is not to categorize individuals
according to a test result nor even as to their overall risk, but rather
to identify those who can be helped, or helped most, by preventive action.
Policy guidelines for screening to assess risk
Copyright © by Eberhard Wenzel, 1997-2001