Personally healthy and socially secure

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THERE HAS been a burst of concern this week about the nation's health. On Tuesday a World Health Organisation report revealed that women in Glasgow top the international league for heart disease, with men there second only to the Finns. This followed a report at the weekend that 40 per cent of applicants for the armed services were insufficiently fit to pass their initial medical.

Last month the British Heart Foundation reported that, quite aside from the deaths caused by heart disease, many people were suffering from it without knowing: 'a quarter of middle- aged men walking the streets of Great Britain have evidence of heart disease,' said Professor Shaper, a member of the BHF's education committee. And at the end of April the British Medical Journal highlighted large health inequalities, both regionally (people in the North are less healthy than those in the South), and between socio- economic classes (the rich are healthier than the poor).

One trouble with this whole debate is that these real concerns tend to be discussed in very politicised terms. Thus the medical profession's response is to call for more money to be put into the NHS. This notwithstanding the fact that Japan, the country with the highest life expectancy, spends no higher a proportion of GDP on health care than we do; and US spending, at nearly three times our own, achieves broadly similar results. Money clearly plays only a small part in improving a nation's health.

The Labour Party blames restrictions on local government, unemployment and lack of investment in house- building, all of which, according to David Blunkett, are 'contributing directly to the rising disparity in health across Britain'. But this ignores some awkward facts: our housing is vastly better than that of the Japanese; while we do have serious unemployment the proportion of our population in work is among the highest in Europe; and, whatever one thinks of our restrictions on local government, the countries that have made the greatest strides in improving life expectancy, such as Singapore, are not necessarily noted for the vigour of their local democracy.

The right equally finds support for its political agenda. The decline of the health of the young, it argues, is a result of the excessively 'liberal' attitude in schools and in particular the failure of today's teachers to involve themselves, as teachers would a generation ago, in organising competitive school sport. And our army recruits are thus less fit than they used to be.

Yet a lot of effort has gone into improving sports facilities for the young, and much of the decline in fitness, if there is such a decline, has to do with attitudes to exercise rather than policy in schools.

In any case, the general health of the nation has in fact continued to improve. Infant mortality, a good measure of general health care, has dropped sharply, while even in areas where we do badly, such as heart disease, we have made some progress: since 1970 we have cut the mortality rate from coronary heart disease by nearly a quarter.

The responses further ignore the weaknesses of other countries' health performance. In the effective use of drugs we are far ahead: a study last year by the US pharmaceutical company Merck showed that 10 out of the top 50 drugs prescribed in France and Italy were useless, and only half the top 50 drugs were ranked as effective. In Britain there were no useless drugs in the top 50, and 46 were ranked as effective. And though more of us die of heart disease, people in the rest of Europe are more likely to die from other causes, so that the overall life expectancy in the UK is virtually identical to that of Germany, France and Italy.

That said, there can be little doubt that we could become a significantly healthier nation. Though there are small differences in health between countries at a similar stage of economic development, there are much larger ones within countries, related to income and social behaviour. The Centre for Health in Society is a new research unit at University College London, formed to examine social and economic factors in health.

The principal research fellow there, Richard Wilkinson, points to Whitehall studies which looked at the health of 10,000 civil servants. These showed that the highest grades had one-third the mortality rates of the lowest. Even when one adjusted for physical factors, such as being overweight, less sporty, and more likely to smoke, there was still a discrepancy.

This raises two enormously important issues for policy. The first is whether it is possible to encourage grand changes of social behaviour, making people become less overweight, take more exercise, stop smoking and so on. The second is whether there is something more we can to do to improve the health of the poor.

As far as the first goes, although there are things which can be done (anti- smoking campaigns are a good example), trying to influence social behaviour is very difficult in a democracy. And politicians are not very good role models.

In any case, while there are things governments can do with taxation and regulation - and things that oppositions can do by example - we should be cautious about the effectiveness of either in influencing behaviour. Changes in lifestyle probably have to start somewhere else in our society and spread outwards, rather than be imposed by a 'Westminster knows best' elite.

But perhaps the most fascinating issue is whether we can give those who feel somehow condemned to bad jobs, or no jobs, a greater involvement in society, and thereby the motivation and self-discipline to improve their health. Take the Civil Service. We cannot promote every junior civil servant to permanent secretary, but maybe we can look at the way people at the bottom of the organisation feel about their lives and their jobs and encourage them to feel a bit more like their bosses. Anyone who knows Japan will recognise that within that society there is a sense of identity: but it is a world where social obligations are more important than personal rights. There is an unexplained factor in Japanese society which probably results in people's better health. Could we create that sense of 'oneness'? Are we prepared, in personal terms, to pay the price?