No Help in Health

BBC News reports on a study that finds death rates from stroke to be three times higher in the poorest areas of England and Wales. This is not exactly the “shock” that they make it out to be as it is well-known that the incidence of stroke is higher in poorer communities. They do have the grace to put the word “shock” in inverted commas.

“The audit of death figures found there were 29 deaths per 100,000 men under 65 each year in the poorest areas compared with just eight in the wealthiest.

“For women, the gap was less at 17 per 100,000 in the most deprived and six in the least, the British Heart Foundation and Stroke Association found.”

The report apparently goes on to suggest that the possible causes of the difference are linked to lifestyle and access to services. I have little issue with the former idea, but the latter is complete twaddle. One thing we do know about stroke causation and death is that it has very little to do with resource allocation (“access to services”). The actual incidence of stroke, the biggest driver of stroke death, is utterly unrelated to availability of resources. It is true that survivors of severe stroke do better in the expensive multidisciplinary stroke units that are resource constrained. However, while the difference in morbidity is significant, the difference in mortality is of the order of 10%.

Of course doctors do make a contribution towards reducing the incidence of stroke. Managing high blood pressure, diabetes and the irregular heart rhythm, atrial fibrillation, significantly lowers the occurrence of stroke and thus, the death rate from it. But these are GP maintenance tasks. Even though you may have to wait a week or more to see your GP, the simple fact is that you will eventually see him/her. A delay of this nature makes no significant difference to your overall risk of stroke. You can afford to wait.

The basic problem is that people in poorer communities do not access their GP regularly. As they need to access a GP three or four times a year at most, it is not cost that prevents them from doing so (in Britain the visits are completely free, AFAIK). Nor is it work commitments. A boss may not want to give someone time off to see a doctor, but it is rare for a GP not to provide some sort of late evening or Saturday morning each week. Transport is also a weak excuse for much the same reason.

The real reason is simple lack of motivation. The prioritization of health is almost directly proportional to the income of the consumer. Most low-income earners just don’t see it as a priority until it starts to deteriorate. And sometimes not then. It is simply not the prime concern.

This attitude extends well beyond regular maintenance checks at your GP. It includes all of the lifestyle measures that are by far the most important part of preventing strokes. All the usual suspects. Stopping smoking, reducing alcohol consumption, eating good food, loosing weight and exercising. All of these things are more likely to be followed in higher socioeconomic groups. This is much the greatest driver of the difference in stroke incidence.

I labour this point somewhat because the inevitable result of codswallop about access is this:

“A national strategy was launched in England in 2007 aimed at giving people earlier access to diagnostic scans and treatment.”

All the effort in these campaigns is put in entirely the wrong place – in making the post-stroke medical response better, instead of working on people’s attitudes to healthier living. People attitude’s are not changed by bans and taxation, they are changed by seeing that the alternative -the healthier lifestyle – is achievable, sustainable and appealing. This has to be done at a grass-roots community level, not in a GP’s surgery or through a series of bright, superficial messages from the government. You can’t pressurize people into good health.

My experience is that government does preventative health in only one way. Very badly.  Doctors are not a whole lot better. For a disease like stroke, where the medical fraternity can offer little more than an expensive get-well card, prevention is everything. And prevention rests almost entirely with the individual because there is no help in health.

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