Epidemiology, history and heartbreak: Reflections from North Yorkshire

As any academic would, I took some work-related reading with me during a short holiday break in North Yorkshire.  Here are some reflections.

First up: Johan Mackenbach’s 2019 book Health Inequalities: Persistence and change in European welfare states.   This remarkable book displays not only the author’s formidable scholarship (there are 738 cited references) but also his laudable willingness to engage with multiple literatures, like those on theories of justice and the politics of responses to inequalities.

That said, there is much to disagree with here – for instance, Mackenbach’s privileging of epidemiology in assessing “what works” to reduce health inequalities, and the selection of relatively crude outcome measures as indicators of success or failure.  A more nuanced approach would better integrate findings from such disciplines as ethnography and programme evaluation, and – in particular – would unpack the fetishisation of “significance” as defined by a 95 percent level of confidence.

This is very different from what might be called colloquial, or more action-oriented, understandings of the term, and population health research and policy need urgently to rethink this definition.  To give a simple and provocative example, many of us individually would take, and are taking, protective measures against coronavirus infection on the basis of far lower than 95 percent probabilities that they would prevent infection.  Public health authorities should be guided by a similar insight.   The combination of privileging epidemiological findings and fetishisation of statistical significance can generate reluctance to infer probable causation that can be pernicious.  Those of us who cut our professional and activist teeth on environmental and occupational health issues learned this decades ago. “We don’t know what works” is a conclusion welcome to the rich and powerful.

Nevertheless, this book is a must-read and an essential resource for anyone seriously concerned with reducing health inequalities.

And then: an even more remarkable volume on Slavery’s Capitalism: A New History of America’s Economic Development, edited by Sven Beckert and Seth Rockman.  Historian Beckert’s previous book, Empire of Cotton, made a powerful case that the textile industry that developed in the early nineteenth century was the first truly globalised industrial production system, enabled by the combination of technological innovation in the UK and the possibilities for low-cost slave labour in the US South enabled by the transatlantic slave trade, with Liverpool as the epicentre first of the slave trade and then, after its abolition in the UK (1807), of the cotton trade.  The edited book is chilling in its documentation of such patterns as the routine use of torture – the lash and more devious instruments – as a way of increasing production, and the use by plantation managers of commercialised methods of scientific management decades before the routine was applied to manufacturing production by F.W. Taylor.

The volume is also a salutary reminder that history matters – a point neglected by Mackenbach, perhaps because of his European focus (there is no index entry for race).  Recent historical analysis indicates that the hard realities of African-American health deprivation in the US must be understood, and responded to, as a global health issue.  Analogously, outside the high-income world, global health research that neglects the destructive effects of decades of ‘structural adjustment’ conditionalities demanded by international financial institutions and driven by the priority of protecting creditor interests is intellectually irresponsible, even if still widespread.

Finally, heartbreak.  A 16 July Guardian article by LSHTM professor Val Curtis described a history of repeated delays in NHS diagnosis and treatment for her now probably terminal cancer.  Read it; any summary would do a disservice to its author, and her observation that she ‘still can’t get my head around the brutal fact that I’m dying’ at age 61.  She correctly notes that: ‘My story is only one of many thousands of people in England whose deaths can be linked to austerity.’  I have trouble containing my rage whilst reading this, and the scandal of almost four million people on NHS waiting lists for elective care has now hit The New York Times.  Like the fate of the Grenfell Tower casualties, Prof. Curtis’ situation demonstrates that policy choices made during the past decade of austerity, like the most recent knock-on effects on the coronavirus response, have been homicidal.  Let’s repeat that word, for emphasis: homicidal.

Whether the health research, policy and practice community are willing to use that word, and to call out those responsible, remains to be seen.

This post was updated on 20 July to add reference to the New York Times article.

‘Lifestyle drift,’ air pollution and the World Health Organization

In 2013 the International Association for Research on Cancer (IARC), WHO’s normally cautious cancer research arm, announced that it considers outdoor air pollution a Category 1 carcinogen – that is, the category for which evidence of cancer-causing properties is strongest.   (The full background monograph is available here.)  This turned out to be one of the most under-reported global health news stories of the new Millennium – like the estimate, the following year, that WHO considered air pollution responsible for shortening the lives of seven million people worldwide.

In 2016, a team of WHO researchers led by Annette Prüss-Ustün updated earlier estimates of the proportion of the global disease burden attributable to the environment, concluding that 23 percent of global deaths and 22 percent of global disability adjusted life years were attributable to environmental risks, although obviously only part of this toll reflects the impact of air pollution.  (I’m happy to say that we published a summary of this work in the Journal of Public Health.)  Importantly, the authors made the point that environmental risks are not primarily a problem of poor countries, or poor people: ‘The lower people’s socioeconomic status the more likely they are to be exposed to environmental risks, such as chemicals, air pollution and poor housing, water, sanitation and hygiene.’  This is certainly true of air pollution, with the highest annual mean concentrations of fine particulate matter occurring in low- and middle-income countries, and the highest urban concentrations of those particulates occurring in Indian cities, with high concentrations also observed in cities like Bamenda, Cameroon and Kampala, Uganda.

WHO now appears to be taking air pollution much more seriously.  Unfortunately, its approach reflects the individualized, behavioural approach (‘lifestyle drift‘) taken by the organization to noncommunicable diseases as a whole, as this screenshot from its website shows:

The solution to pollution is to hold your children up out of the car exhausts?  Try exercising in less polluted areas?  (If you live in London, maybe drive to Somerset for your jog?)  One couldn’t make this stuff up.