SICK SOCIETIES: RESPONDING TO THE GLOBAL CHALLENGE OF CHRONIC DISEASE.

     Stuckler D, Siegel K (eds). Oxford University Press, 2011.



By Virginia Gray, Ph.D., R.D., and Jessica Murray

 

Sick Societies: Responding to the Global Challenge of Chronic Disease makes a case for social, political, and economic factors that have created living environments poorly designed for health, thus contributing to a global rise in chronic disease. While the pervasiveness of chronic diseases across all sectors of society argues for population-level measures to reduce disease rates, inequities in chronic disease rates call for particular strategies to impact the most vulnerable. Formulation of intervention strategies must consider the roots of chronic diseases (“the cause of the causes”). Furthermore, from a social justice perspective, a clear understanding of how social, political, and economic factors may limit health-promoting behaviors among those most vulnerable to chronic disease is needed. The book provides an overview of the global chronic disease burden, its causes and consequences, and potential means of intervention. Policy and practice points are included at the beginning of the chapters.



The book begins with an examination of the global burden of chronic disease (Chapter 1). It presents a compelling case that chronic diseases are not simply diseases of aging or affluence, as evidenced by premature development of chronic diseases and the rapid growth of chronic diseases in poor countries in comparison to rich countries (with chronic diseases causing about 80% more deaths than infectious diseases in low- and middle-income countries). This creates a “double-burden” of disease in resource-poor countries, with deaths due to chronic disease occurring at younger ages and involving more years of associated suffering.



After establishing the extent of chronic disease, the book turns to an exploration of the social determinants of chronic disease (Chapter 2). It presents a case to support investigation of specific biological factors (rather than behavioral risk factors) in combination with investigation of the underlying social causes related to chronic disease risk. While significant evidence has identified risk factors for chronic disease at the individual behavioral level (e.g., tobacco use, unhealthy diet, physical inactivity, and alcohol use), the constructed living environments conspire against healthy behavior. The authors argue that an adequate understanding of the distinctiveness of causality of disease at the individual and population levels is key. The impact of societal changes such as economic growth, trade liberalization, and technological advance are introduced in this chapter and elaborated on in subsequent chapters. In response, strategies for intervention are discussed, such as advertising and smoking bans, financial interventions (such as taxes and subsidies), regulatory initiatives, and labeling initiatives. This chapter could be strengthened by a more thorough explanation of the potential applications related to differences in biological chronic disease risk.



In Chapter 3, the social and economic consequences of chronic disease among individuals and societies are explored.  The authors argue for a perspective that views health spending as an investment for reducing poverty and improving the economy, rather than thinking about healthcare simply in terms of cost containment.  The authors argue that such a shift from cost containment to viewing health spending as an investment has occurred in addressing certain infectious diseases worldwide (malaria, tuberculosis, HIV/AIDS, etc.), yet the paradigm shift has not been extended to chronic disease. Elaboration of how this shifted focus occurred, with applications toward a greater political priority towards chronic disease prevention, would be helpful. In addition, better elaboration on the economic language used in this chapter might increase the accessibility of the discussion to non-economists.



After discussion of the burden, determinants, and consequences of chronic disease, the book then turns to discussion of strategies to reduce chronic disease. In Chapter 4, the authors call for a reorientation of healthcare delivery that is centered around patients living within communities and that is characterized by horizontal, rather than vertical, integration. Discussion of the residual influences of the ”smallpox paradigm” on modern healthcare delivery is included. The argument for greater patient engagement calls for a view of the individuals in need of healthcare as possessing assets that can help solve the problems discussed in the book. While recognizing the role of healthcare, the authors recognize the inherent limitations of reliance upon healthcare systems to change population health.



Chapters 5 and 6 describe the context of power and politics in which the battle against chronic disease is fought. First, the role of private donors (who contribute about half of global health money) in setting the global health agenda is explored. The sparse global health funds directed at chronic disease prevention is contrasted with the vast majority (97%) of global health funds focused on quick fix solutions, in line with the “smallpox paradigm” presented in Chapter 4. For example, access to retrovirals for HIV-positive individuals is much higher in many developing nations than is access to insulin. The political involvements of private donors (i.e., ties with food and pharmaceutical industries) are discussed in relation to the “agenda setting” of the global health agenda. This section of the book also highlights conflicting views on the role of the food industry in addressing chronic disease. PepsiCo staff currently leading the company’s global health and wellness strategy present current industry efforts to address chronic disease (e.g., product reformulation to reduce fat, sodium, and sugar; self-regulation in advertising; etc.). The importance of trust and public-private partnerships based on shared values is emphasized. This is followed by a counter-argument that corporations have goals, which fundamentally conflict with public health. In light of the conflicts of interest within the private sector as well as among other decision makers (government and non-government agencies), a call is made for a reorientation of decision making related to global health priorities. Emphasis is placed on using disease burden and subject matter expertise to drive decision making so that funding and policy interventions are objectively and holistically directed.



A strength of this book is the use of case studies and country comparisons to illustrate how health status is sensitive to factors that are not directly related to nutrition or disease transmission. Chapter 7 presents a series of enlightening comparative case studies of countries (Brazil, China, India, Mexico, and South Africa) selected based on double burden of disease and recent, rapid economic growth. These case studies are included to help identify common causes of chronic disease at the population level and to provide examples of intervention strategies. Rapid industrialization and urbanization, in combination with embracing of a free-market economic model has resulted in a pattern of uneven development in these countries. Lack of investment in public infrastructure (such as sanitation systems); a shift from traditional staples to modern diets that emphasize meat, oils, and dairy; and loss of agricultural jobs are among the results. Common intervention strategies are also seen among these countries, such as use of media to convey public health messages, use of urban planning and transportation policy to improve physical activity, tobacco bans, regulation of false information on packaging, school interventions, etc. This chapter serves as an encouragement to public health professionals to engage in global networks, as many countries are facing common health concerns.



Sick Societies presents a compelling case for population-level interventions and for a social movement to reframe the discussion of chronic disease, focusing on its social embedded-ness.  From a social justice perspective, individual interventions run the risk of widening inequalities in health status because higher socioeconomic status (SES) groups tend to be more able to change behavior compared to lower SES groups. “Part of the problem is that we often falsely leap to the conclusion that the prevention of (chronic disease) is a matter of education. This assumes a great deal of agency and choice among the affected population” (p. 132). The theoretical base of many public health campaigns is that people do not know that their lifestyle choices (alcohol use, diet, exercise, etc.) are damaging. If, however, healthy choices are limited, education campaigns offer very little. If root causes to increased chronic disease are at the societal level, it follows that solutions should be at the societal level.  Sick Societies illustrates that chronic diseases are not simply illnesses of affluence or aging, and that biomedical and educational interventions are insufficient in dealing with the shifting tides of global health. Current funding and priority for chronic disease is inadequate, unsustainable, and too frequently seen as an issue to address down the line. A coordinated approach that considers the root causes of chronic disease in order to develop intervention strategies for population-level change is needed.




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Virginia Gray, Ph.D., R.D., is Lecturer in Nutrition in the Department of Family and Consumer Sciences at California State University Long Beach. Jessica Murray is a graduate student in Nutritional Science at California State University Long Beach.

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