Fortsetzung Health in all Policies? Rethinking Prevention
People are Stakeholders in Prevention
If needs, preference and situation of the targeted people are not considered, then the entire preventive process may derail, resulting in people refusing rationally based and justified measures. Instead they may resort to their own “decisions”, whether overtly or covertly; in any case behaviour is not changed (7, 13). An often-cited example is the top-down introduction of “healthy school meals” in the UK, where upset parents resorted to handing over what they felt was the „rightful“ food for their children at the school fence. Interestingly, the nutrition intervention had significant effects on scholarly outcomes (4). When appreciating the importance of accessible, attractive and understandable information, the scarcity of formulated guidelines or health policies exist in most European public administrations that are accessible to the normal citizen is simply astonishing (18). Thus, if people do not adopt to what is scientifically deemed to be rationally justified as „proper“ behaviour, we should ask whether society has failed to appropriately convince these individuals rather than finger pointing on individual irrationality (4). We have learned from school-programs, that bottom-up-approaches which respect the targeted individuals are very successful and have health and economical outcomes (12, 13, 14, 15).
Therefore, people should not only be considered as targets of (preventive) measures. They must be involved as active participants in an interactive process in which their voice, their concerns and their ambitions are valued. In this way, measures can be co-developed in a way in which they can contribute their legitimate interests (1, 4, 14). This concept of stakeholder involvement – as unfamiliar for a more paternalistically oriented specialty such as medicine – does not only address the target group of measures. It rather describes an interactive process of all stakeholders involved from the private, public, social and political environment. In an ideal decision-making process, all stakeholders communicate with each other, negotiate on measures, make joint decisions, accept and adopt them (7). Here, medicine can learn from other sectors of the economy, where customer orientation and understanding customer reality have long been key components of success. The difference compared to prevention is that success in business translates to increased profit, while the revenue from prevention is an increased number of life years spent in good health (9).
As communication is important, modern social media should facilitate information exchange. In reality, however, we find great imbalances and even a simple lack of facts, if not lies. This situation may be created by private or sociopolitical interest groups, but also by cultural and language differences. Such biased „information bubbles“ are problematic as they support the self-exclusion of certain groups from real social communication and facilitate adoption of non-evidence-based “alternative” facts – whether intentionally or unintentionally. Private or public interest groups nowadays exploit such mechanisms to influence public processes, further complicating the preventive efforts. This leads to a climate of persistent mistrust in which people perceive decision-making processes as non-transparent.
Thus, they come to believe that groups with financial and intellectual resources are better able to influence decisions, while others try to prevent action through legal action. Covid-19 illustrates in fast-motion, how this rapidly may lead to the perception of being excluded or not being considered in decision-making, which in turn emotionally „justifies“ refusing advice (11). Therefore, in modern democratic societies, new models of citizen participation must be explored, for example citizens‘ forums and advisory councils. So far, however, not all groups are represented in these processes, which is why such a co-creation process needs to be continuously explored and improved.
Health Policies must be Publicly Negotiated
Given the importance of accessible, attractive and understandable information, it is astonishing how few formulated guidelines or health policies exist in most European public administrations that are accessible to the normal citizen (18). Policies can be defined as „decisions, plans and actions that are enforced by national or regional governments which may directly or indirectly achieve specific health goals within a society” (4, 18). Policies should create supportive environments to stimulate a healthy lifestyle such as healthy diet and physical activity (and/or discourage sedentary behaviour) (3, 18) – but for the most, official publications lack the sharpness by individual contributors that can already be found on social media such as Instagram©.
Many public decision-makers try to make the best possible use of public resources, to invest and spend money carefully. Nevertheless, there are considerable differences when it comes to formulated policies. Some countries like the US, Canada, Australia, Great Britain or the Netherlands are much more advanced, Germany is more on the libertarian level (18). Perhaps this was often considered unnecessary or too complicated (if one does good, one does not need to talk much about it) and the potential of stakeholder dialogue for the development of health policies was underestimated (1).
The Role of Medicine is Changing
There is no single doubt that scientific medicine is crucial for understanding diseases, their development and the immediate treatment. A differentiated health care system is part of the basic structures of modern societies (7). Enormous progress has been made by analysing diseases to uncover the pathophysiological, biochemical and molecular basis in order to develop therapies, technologies and drugs. Thus, most treatments in hospitals and medical practices are also primarily oriented on processes of immediate illness amelioration and efficiency. When treating an acute heart attack or operating on a fractured neck of femur, medicine is champion and prevention and lifestyle naturally momentarily fade into the background. However, although more sophisticated therapies and technologies become available, due to the magnitude of related costs, the budgetary resources available for the health system are becoming increasingly scarce.
Health economics shows that in modern developed societies like Germany or the US, health care services costs and outcomes are not closely related (7, 8). For example, the USA is spending 50% more of the GDP (total market value of all final goods and services produced in an economy for a given year) on health care services than any other industrialised country, yet the outcomes of this costly healthcare system are at best mid-table (20). The focus of the USA healthcare system is mainly on high-level procedures and technologies as well as on controlling internal costs and creating revenue. These systems create meaningful outcomes of survival and lower rates of impairment for few affluent patients, while at the same time large inequalities in access to health care and public health continue to further increase (20).
Thus, in order to be involved in the long-term health development of humanity, medicine must start focusing more on the well-being of individuals outside of hospitals (7, 8). Long-term changes in life-style can only take place where people live, meet and move.
This should also be considered against the background of the growing importance of the environment and lifestyle in the development of diseases such as depression, type II diabetes, etc. as opposed to a genetic predisposition (7, 21).