Long Read

Health is Made at Home, Hospitals are for Repairs

Our health services have been fighting for our lives for the last few weeks and months—throwing all their resources at the pandemic. Millions of health and care workers have been magnificent, rising to the occasion with bravery and skill. It has demonstrated, among other things, that we must support and resource them better for the future.

Governments have also played a role in providing leadership and direction, introducing emergency legislation, supporting the health services and the economy, and, of course, managing re-opening, recovery and, ultimately, the distribution of vaccines and treatments.

There will be many lessons to learn from the different approaches taken, their successes and failures. We are probably still in the early days of the pandemic and it is too soon to make judgements about big issues like central versus local control, and health impact versus the effects on the economy. Some leaders and governments already stand out as excellent, and some as appalling. There may well be second and subsequent waves of the virus to come and we know that health, the economy and society will be affected for many years to come.

The pandemic has not just been about health services and governments. It has largely been up to us, the general public, how far and how fast the virus spreads in each country. Our behaviour matters. Millions have volunteered to help, kept community and voluntary activity going, or simply looked after neighbours. Millions more have kept the vital non-health emergency and other services running in agriculture, retail, delivery, power, transport, finance, rubbish collection and so much more. We have all had our part to play.

The public has always had a vital role in health and it always will. The pandemic has simply made it very visible and reminded us that we all have a responsibility for safeguarding and improving health. Health services and health professionals cannot do everything by themselves. They cannot deal with many of today’s major health problems such as loneliness, stress, obesity, poverty and addictions which have such massive societal impacts. They can only really react, doing the repairs, rather than addressing the underlying causes.

There are, however, people all over the world who are tackling these causes in their homes, schools, workplaces and communities. The leaders and pioneers. I have met some of them in the UK. People like the teachers in a rural area working with children excluded from school, the unemployed men in a northern town who are improving their community, the bankers tackling mental health in the City of London, and many others. I know there are people like them in every part of the world. I think of m2m, ‘mothers2mothers’, in southern Africa where mentor mothers support pregnant women who have HIV to avoid passing it on to their children. Or the weaver communities in the Thar desert in India. Or the voluntary groups working with homeless people in the US.

These pioneers are taking control for themselves. Not waiting for government or health professionals to tell them what to do. Breaking new ground, taking the initiative and leading. They are not just preventing disease but creating health, focusing on the causes of health while the professionals concentrate on the causes of ill-health.

There is a very important concept here – health creation – which must be distinguished not just from the provision of health services but also from the prevention of disease and promotion of health. Prevention and promotion are generally focussed on individual diseases or problems – heart disease or the negative impact of smoking for example – where health creation is both more holistic and more positive. Creating something, not dealing with a problem.

The pioneers I have been meeting are creating health by which I mean providing the conditions in which people can be healthy and helping them to be so.

It is what a parent does when they care for their child, helping them grow up to be healthy. What a good teacher does, or a good employer. All of them exercising a profound and positive influence and helping create resilient, confident, capable and healthy individuals.

The health creators are not just preventing disease but creating health, focusing on the causes of health while the professionals concentrate on the causes of ill-health.

There is a long tradition here of salutogenesis – literally the beginning of health – exemplified in the approach of many traditional cultures to child-rearing and to health. The ancient Greeks had a similar concept called eudaimonia by Plato and Aristotle and commonly now translated as human flourishing.

The definition of health, agreed by the World Health Organization at its foundation in 1948, reflects this holistic approach:

‘Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.’

Health and wellbeing are about life and freedom, being all that we can be, and living life to the full. They are about our relationships, how we live, and what happens to us at work and at school. They are about confidence and control, and the quality of our lives.

Because of this, our health as individuals is intimately connected to the health of our communities and our society – and, ultimately, our environment and our planet.

As we continue to struggle with the pandemic, it is worth reflecting that a new emphasis on health creation will not only improve our lives but will also take some of the pressure off our health services and our health professionals, making sure they are always there when we need them.

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Our health systems need reform. In Europe, America and the industrialised countries of the world we are attempting to deal with today’s health problems by using health systems that were designed to tackle yesterday’s diseases. It is no wonder there are so many difficulties.

Today’s health problems are very different from those that these systems had to tackle when they were founded 60 or more years ago. Then, people were much more likely to die of infections, in childbirth, in factory accidents, and on the operating table. There was no relief from arthritic hips, cataracts, blocked arteries and damaged heart valves. Old age really did start at 65 and death often followed fairly soon afterwards. It was a very different world.

Today, there has been near miraculous progress. We are healthier and life expectancy has increased by almost a quarter. That means on average almost 15 more years for each of us since the second world war. Better sanitation, housing, social benefits and education have all played their part. New drugs and therapies are now bringing many of the most frightening diseases under control.

There is the promise of much more to come, with genetics, artificial intelligence (AI), pharmacology and new technologies holding out the hope of personalised precision medicine and the cure for all our ills.

That is not the whole story—perhaps not even the bigger part. The COVID-19 pandemic has jolted industrialised countries out of any complacency we may have had about the risks from infections. Tuberculosis is resurgent, HIV/AIDS never went away and the threat from new drug resistant infections (antimicrobial resistance) is growing all the time. Low and middle income countries have continued to face these problems all along with outbreaks of Dengue, Ebola and Zika virus as well as endemic problems of malaria and neglected tropical diseases. We can all expect more pandemics and more localised epidemics in the future.

At the same time, recent figures show that life expectancy in some industrialised countries is stalling as long term conditions and lifestyle diseases take hold. Loneliness can be a precursor of dementia, stress shortens lives, obesity can lead to diabetes, poverty is linked to cardiac and other diseases, and addictions cause multiple health problems. The pandemic is wreaking havoc but these chronic health conditions remain the biggest areas of disease and, in the longer run, will be the greatest cost to the health systems and societies. The health professionals cannot deal with them by themselves.

These problems are made worse by increasing divisions in many countries, the growth of political extremism coupled with greater stress and insecurity in school and at work, and by growing inequalities. Years of austerity in some countries have created a sense of public neglect while Brexit in the UK has highlighted old differences and created new ones.

The pandemic has revealed to people in industrialised countries some of the half-hidden truths about our societies. Migrant workers do so many of the lowest paid and insecure jobs. Millions are on zero hours contracts with no support. Poverty, inequality and ethnic divisions have been exposed. We may all have been in this together, but it has impacted us very differently. This is making us confront the uncomfortable reality that the old normal was bad for many people.

The killing of George Floyd and the world-wide reaction through the Black Lives Matter campaign have reinforced these points and drawn particular attention to the disadvantage faced by people of colour and by ethnic minorities in countries around the world.

All this has demonstrated the fact that the health of individuals is intimately linked to the health of communities and society more generally. Sir Michael Marmot and colleagues have provided much of the vital theoretical underpinning by showing how society and inequalities affect health and life expectancy. The social determinants of health – upbringing, social status, education, environment, opportunities and income—affect our health and life chances.

This understanding has led to the development of an approach which has become called “Health in All Policies”, originating in Finland and subsequently spreading to other European countries, Australia and elsewhere. It explicitly reviews the health implications of policies in all areas from education to employment in an effort to improve health and to find synergies between health and other public objectives.

Such an approach is particularly important in thinking about child-rearing. Sir Harry Burns, former chief medical officer in Scotland, explains what this means for children in some communities: ‘… a chaotic early life leads to a reduced ability to manage stress and behave appropriately … the biology is very clear: chaotic difficult circumstances lead to increased risk of physical ill health’.

He continues: ‘So let’s not spend a fortune trying to find drugs to fix that. Let’s change the chaotic and difficult circumstances so that they don’t happen.’

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Health in all policies challenges governments to change the way they make policy, to join up action across sectors and invest for the long term. It is no surprise that, despite some gains, government’s policies are not yet adjusting at any scale to match this new understanding. But policy is not everything and sometimes makes little difference in reality. Improving health and wellbeing is not just about government policy.

As importantly, there are many people and organisations who are not waiting for governments but doing something about the problems they see in front of them. These pioneers are taking matters into their hands. Working with the professionals but not for the professionals. And in some cases, despite the professionals. Taking responsibility. Taking a lead. Taking control.

These pioneers, the innovators and the leaders – the health creators – are making a difference in their workplaces, schools, towns and communities. They are tackling stress and mental health, providing education and support, promoting physical activity and healthy eating, helping reduce crime, and designing healthy environments – bringing creativity and new ideas to bear in a bottom-up revolution.

I learned the saying ‘Health is made at home, hospitals are for repairs’ from Francis Omaswa— a great African health leader. It is notable that health creation is far more common in African and other low and middle income countries which do not have the resources of the industrialised countries. Their populations have never completely lost their role in maintaining and improving health. Nor have they handed over power to the health professionals and institutions in the way that richer countries have done.

Observing the health creators at work, I would add that health is made at home and at school, in the community, the workplace and wider society.

Health is made at home and at school, in the community, the workplace and wider society.

Health creators are not just improving health. They are building and rebuilding communities as places where people matter, where everyone has something to contribute and where, crucially, we can have greater control over our lives – something we all need if we are to be healthy and fulfilled.

A strong moral sentiment that ‘we have to do something’ runs throughout their actions. It is there among the employers in the City of London who are tackling mental illness. It is both good for business and the right thing to do. Mental illness, stress, depression and anxiety have taken over from physical health in recent years to become the biggest health issues in the workplace, costing the UK economy about £80 million a year but also damaging many thousands of lives.

The sentiment is present in the determination of the people rebuilding their communities all around the country, and in the architects designing detention centres and other stressful environments in ways that are human and humane. And it is there in people fighting inequalities and advocating the rights of minority groups.

Perhaps it is even more strongly evident in the people working with children and young people. Getting it right for children at the start of life can avoid so much expenditure later, as well as so much pain and suffering.

There are several other major themes that characterise the work of the health creators. Good health in older age is largely dependent on having a meaning in life as well as being active socially and physically. These are factors like creativity and the arts, which are important at all stages of life. Pioneers such as the group of largely unemployed men improving their housing estate near Manchester, and the Black Health Initiative reinforce the importance of communities of all different kinds.

The importance of the natural environment shines throughout, whether in gardens and green spaces in hospitals and housing estates or in the sheer calming effect of greenery and the countryside on adults and children alike. Similarly, the quality of the built environment and the accompanying sense of place, identity and belonging are important for our health and wellbeing.

These health creators all take a broadly entrepreneurial approach, vision-led and learning by doing. Many are social and community entrepreneurs while others are in business, melding profit with social benefits – whether in vertical farming, providing care or supporting young parents. All of them are focused on action, making things happen and taking control of the situation as they find it.

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Health creation is a challenge to professionals in much the same way that health in all policies is a challenge to governments. They need to adapt their whole approach to take account of these new ideas.

As a former chief executive of the English National Health service (NHS), the largest health service in the world with 1.4 million employees, I know that this change will not be easy or rapid.

Like other health systems in industrialised countries the NHS was shaped by the culture, technology and political agreements of the immediate post-war period. This led to a system where doctors and hospitals were dominant, the focus was on treatment not prevention, patients were managed within specialities, and there were organisational and cultural divides between services and institutions. Despite many reforms, these founding conditions remain very powerful.

Politics too often presents us with false choices. The two major parties in the UK – like many political parties around the world – have long stood respectively for the market and for state control. The health creators are recreating the third pillar – community or civil society—in doing so, they are creating health, putting caring back into society and rebuilding communities. They are in the vanguard of change.

In what could be a positive sign, politicians of all parties seem to be beginning to rediscover community and communities.

It is time to bring the health creators in from the cold, to recognise and support their work and to develop strong partnerships with health systems and government – each bringing different skills and experience to the joint enterprise of building a healthy and health-creating society.

Nigel Crisp
August 2020