1336
Reappraisal SOCIAL MEDICINE AND ITS CONTRIBUTION TO SOCIAL POLICY* F. M. MARTIN
University of Glasgow Department of Social Administration and Social Work, 53-57 Southpark Avenue, Glasgow G12 8LF
the Royal College of Psychiatrists. Was it a remarkable degree of psychological liberation, or mere naivete, that permitted the disclosure of so many anxieties, insecurities, and identity problems when the psychiatrists had to stake out their position in relation to general medicine? For social medicine, which has never had the advantage of actually treating patients, even of the wrong kind and with the wrong kinds of disease, the task of constructing an identity has been yet more difficult. The way in which a solution has been sought goes a long way to explaining why the social-policy contribution has been so
review of the achievements of the academic disciof pline social medicine over the years of its existence, one of the questions that must be asked is what has been the contribution of social medicine to social policy in general and to health-services policy in particular. There may be a doctoral thesis to be won by sieving through the products of academic social medicine in order to capture a few specimens of policy-oriented research, and by painfully reconstructing the relevant policy processes in order to show what part, if any, such research has played in their formulation. Yet it might well turn out to be the kind of research which involves the lavish use of bulldozers to demonstrate the fragility of eggshells. At the risk of being accused of cavalier over-generalisation, I would simply assert that academic social medicine’s contribution to policy has been small, and I would like to ask why this should have been so. No-one emerges particularly well from such an inquiry, neither doctors, In
nor
limited.
a
sociologists,
nor
policy-makers.
STAKING A CLAIM
Each
new discipline or sub-discipline has to make its in the academic or professional world, to define its way to identity, offer to its chosen audience some conception of what is- central and distinctive to itself. Almost invariably this has to be done within contexts constructed by already established professions and specialisms, and the task for the newcomer is largely one of locating itself within the often competing frames of reference which they provide. For a discipline coming within the ambit of medicine, the task of self-definition may require both intellectual agility and moral strength of a high order. The luminous prestige which attaches both to certain kinds of clinical excellence, and to a distinctive tradition
EPIDEMIOLOGY AND BEYOND
The pre-eminent concern of academic social medicine has unquestionably been the development of epidemiological methods and their application to the investigation of disease. Epidemiology involved direct access neither to the bedside nor to the laboratory; for the most part it took specific disease entities as its points of departure and could fairly claim to add a new dimension to clinical thinking. Any textbook of medicine could have, as it an epidemiological appendix to each chapter. That pursuit of epidemiological inquiries has added substantially to the advancement of medical knowledge is indisputable. It would be churlish even to question its right to the first rank among the contributions of academic social medicine. Yet the discipline has made no comparable intellectual investment either in the study of
were,
the
those processes which underlie the causal links identified in epidemiological studies, or in the detailed examination of the health-care implications of disease patterns. Those researchers who have with great care examined the role of smoking habits, dietary characteristics, alcohol intake, and other aspects of human behaviour in relation to various diseases, have tended to show little interest in the behavioural forms themselves, which stand no less urgently in need of investigation. Serious investigative work was required, for example, to pin down beyond dispute the connection between medication with thalidomide in early pregnancy and specific types of damage to the fetus. There were of course also some who paused to ask why it was that such huge numbers of pregnant women found it necessary to swallow so many tranquillising drugs; but I doubt whether anyone looked equally imaginatively for an answer.
of medicoscientific research, creates potentially crippling psychological difficulties for the new arrivals. Once the values associated with the established dominant specialties have entered deeply into one’s basic conception of what being a doctor means, it seems very difficult to establish an area of medical enterprise free from the magnetic fields of these values. For those medically qualified people who choose occupations where the relevant skills, knowledge, or subject-matter are remote from the concerns of the focal specialisms, building up identity and self-esteem is nearly always difficult. Psychiatry, unquestionably a clinical specialty, but with an atypical set of problems, concepts, and methods of investigation, is
interesting example. There is a fascinating analysis waiting to be carried out of the correspondence in the medical journals that preceded the decision to establish an
*Adapted from a paper given by Professor Martin at a symposium held by the Society for Social Medicine in Birmingham on Sept. 14 to mark the society’s 21st birthday.
PARTNERSHIP WITH THE SOCIAL SCIENCES
If there has been marked reluctance to enter the waters of motivation attitudes,’ culturally patterned behaviour and expectations, there has certainly been a greater readiness to examine systematically topics within the area of the provision and organisation of treatment and supportive services in response to healthcare needs. But these studies have not been carried out on such a scale, or at such a level of sophistication as epidemiological investigations, and have generally been regarded as fairly simple extensions of epidemiological inquiry, calling for few basic changes in conceptualisation or research method. We have rarely done justice to the multidimensional complexity of the planning, organisation, deployment, and utilisation of healthcare systems, and for that reason-among other powerful reasons, to be sure-we have had little impact on policy. To do this adequately would mean giving a
murky
1337 limited place to concepts and methods derived from medicine and statistics, and entering fully into a productive relationship with the social sciences-pretentious, verbose, and frequently confused though they are. Very few practitioners of social medicine have been prepared to hazard their medical identity to such an extent; and, perhaps more surprisingly, few have been able to achieve really effective working relationships with sociologists of comparable seniority. If we are to apportion responsibility, however, we must have regard not only to the over-caution of many physicians, but also to the irresponsibility of many sociologists. The relations between medicine and sociology could perhaps be likened to a marriage which had been based on false expectations and gone sadly wrong. Few would be misled by the male partner in the marriage-old Dr Medicine, kindly, benevolent, but a bit of a male chauvinist. He would be a decent enough husband, and his new bride would know her proper place and remain modestly within it. We can imagine his dismay when the little lady--or Ms Sociologia, as she insisted on being calledannounced that she was a dedicated member of an unspecified liberation movement, and intended to spend her time in marriage not in the academic equivalent of mending the old man’s socks and cooking his dinner, but in proclaiming the autonomy of sociology and denouncing medical domination. But metaphors apart, I think we may have been misled by a false analogy with statistics. Statistics has been a splendid ally to clinical medicine and epidemiology. The physician can go to a competent statistician and ask how statistical methods can be employed to find a solution to a particular problem, and the statistician will give an answer, even if it’s only that the problem isn’t soluble. To go to a sociologist with a similar request for help is to risk disappointment. What the sociologist may say is: "That’s an interesting problem, but before we think about answers can we look at it together and make quite sure that we’ve got it right? We want to be careful that we haven’t prejudged the issue, or written in any value-laden assumptions. There may be some components of the situation which have too readily been taken for granted, and perhaps need to be analysed explicitly". Such a response, capable of leading to a creative reformulation ot a problem, is positive and thoroughly professional. However, some doctors have found such a response difficult to accept, since it seemed to challenge their professional right to define issues and problems (although in fairness it must be said that it is very much easier now to engage in such dialogues than it was once). There is however another possible sociological response to the doctor who comes presenting a problem for solution. It runs roughly as follows: "Actually, I don’t think that’s an interesting problem at all, and I’m not in the least interested in solving it, because it would do nothing to advance sociological theory. Now, what I would really like to do is make a lot of taperecordings of doctors talking, and then write a fascinating paper analysing the peculiar processes that doctors go through in deciding what their problems are". The physician may well conclude that this is less than helpful. Sociologists of this persuasion, who complain that medical practitioners want to use them in a vulgarly instrumental way, must really not be surprised if they find themselves in deepening isolation.
RESEARCH AND POLICY
more
During the 1960s sociology in this country grew at a which perhaps outstripped the capacity of its roots to provide adequate intellectual nourishment; as a result some of its tendrils are blown about by every breeze of intellectual fashion. Between those for whom sociology
rate
is an instrument for fighting the class war, and those whose main allegiance is to ethnomethodology, it is sometimes difficult to discern the central core of theoretically informed and imaginative empirical research. It is there, of course, and in two or three centres medical sociologists have been doing research of a very high standard, even though the discipline’s overall achievements have fallen some way short of its potential. Contributions to policy, however, have not been far-reach-
ing. In the history of the relations between policy-makers and researchers in general, mutual misunderstandings and lost opportunities abound. The research community as a whole, when it has not turned its back on policy questions, has tended to have a naively simplified view of the policy process. It has felt aggrieved when the findings of research were not immediately incorporated in legislative or administrative measures, underestimating the part played by less rational forces-the activities of pressure groups, political and social ideologies, and, of course, sheer inertia-and striving for precision and clarity in policy-making where ambiguity and even inconsistency are inescapable. Policy-makers for their part are usually fairly clear about what’s wrong with research-it’s too late, it’s not relevant, the methods are crude, it doesn’t tell them what they want to know. But they also find it difficult to be specific about just what kind of research input into policy they positively want. It worries me that one of the few examples I can recall of a piece of research that was immediately and compre-
hensively incorporated into health-services policy was a thoroughly ill-conceived and misleading study-the 1961 prediction of changing mental-hospital occupancy rates, which really had nothing going for it apart from the self-confidence with which it was expressed. It is correspondingly depressing to contemplate the history of other changes in the health and related services, and to see how rarely research has influenced developments. It is hard, for example, to see what conceptual or research input went into the 1974 reorganisation of the National Health Service, apart from a few shreds from the rag-bag of management consultancy. And the crudity of most thinking on resource allocation is staggering. Then there are the policy questions that so far seem not to have been asked at all where the policy decisions are made-on how, for example, appropriate health care can be made usably available to members of socioeconomic groups whose inferior health own discipline has so fully documented.
status our
WORK TO BE DONE
Perhaps we should not draw pessimistic conclusions, and infer that good research can never find a receptive audience. However, there are some requirements which, for an effective contribution, must be fulfilled. First, policy-oriented research workers must understand the realities-the constraints and opportunities-of policy-making. Then a shift away from strong identification with a discipline, and from a strict allocation of work on
1338 human behaviour and organisation between established
disciplines,
is needed, though this is undoubtedly a difficult and almost threatening requirement, given the present structure of our professional and academic life. Finally, there should be a greater readiness to consider new research styles, with less emphasis on the formal long-term project, and more on studies which are constructed to allow for interchange between researcher and policymaker, and which can unashamedly change direction. All of these are hard demarids, and it would be surprising if more than a few workers were prepared to meet them. Some people may feel that it is unfair to criticise a discipline, even gently (and I know I have exaggerated), for the limited scale of its contribution in an area which many have not seen as really their pro-’ vince. But there is work to be done, work ofthe highest social importance; and it is up to those who are potentially the best qualified to do it-the members of the discipline of social ’medicine-to go ahead and seize the ’
.
opportunity.
THE FAILURE OF PREVENTIVE MEDICINE
J. A. MUIR GRAY Oxfordshire Area Health Authority (Teaching), Health Offices, Greyfriars, Paradise Street, Oxford OX1 1LE The failure to promote public health may be due, not to political or economic but to the fact that the arguments used to opposition, persuade people to change their behaviour or to agree to the passage of enabling legislation are set in a linguistic framework which has no meaning for them—namely, the concept of the future.
Summary
INTRODUCTION
ALTHOUGH preventive medicine has been widely accepted in principle, in practice progress has been very slow. Since the 1939-45 war, the only significant advances have been the development of comprehensive immunisation programmes, the Clean Air Act, and the legislation which made the wearing of crash helmets compulsory. There have been no sweeping measures, no Acts put on the Statute Book to compare with the Public Health Acts. Although "piecemeal social engineering" (the development of social policy by attacking individual problems rather than by attempting to create utopia by large-scale planning) is now, quite rightly, regarded as laudable, the small and hesitant steps taken to reduce the noxious effects of cigarette smoking, drinking and driving, driving without seatbelts, alcohol, and dietary imbalances, cannot be justified on the grounds that they are piecemeal. Epidemiology has revealed evidence that is at least as strong as that which led to massive changes in the 19th century and on which we could base policies to reduce the problems of cigarette smoking, road traffic accidents and problems caused by alcohol and dietary imbalance. Another disturbing aspect of the failure of preventive medicine is that the social-class differences in morbidity
and mortality appear to be widening and those personal preventive measures which are advocated by health educators have least impact on those most at risk-namely, people in social classes Iv and v.
WHY PREVENTIVE MEDICINE IS FAILING
One hypothesis rests on an economic premise-that the country "cannot afford" to act. This argument has been applied particularly to cigarettes and alcohol. However, an elegant analysis of the cost of cigarette smoking shows that it includes more than just the cost of treatment.Considering other costs, apart from treatment, there is a sound economic argument in support of increasing taxation on cigarette smoking; the same argument applies to problems related to alcohol abuse. In any case, if people did not spend their wealth on cigarettes or alcohol, they would have to dispose of it in some other way which the Treasury could tax to raise the same amount it now obtains from excise duty on tobacco and alcohol. Another hypothesis is based on a political premisethat politicians place a low priority on preventive medicine. The reason suggested is that the disease lobby, the movement to promote public health, is less powerful and less effective than lobbies which represent the financial and employment interests which would be adversely affected if measures were taken to prevent disease. The weakness of the disease lobby has been cited as the main In spite of reason for the success of the other lobbies. its failings, however, the profession is at last firmly behind preventive medicine. The reports of the Royal College of Physicians on smoking and fluoridation, the British Medical Association’s excellent work on road safety, and the activities of the Medical Council on Alcoholism and ASH (Action on Smoking and Health) indicate the strength of support, yet little action is taken. My inference is that politicians are slow and unwilling to act because they represent the people and reflect the public’s unwillingness to accept such legislation as that
random breath-testing, on restrictions on advertising, increased taxation on tobacco and alcohol. This is the paradox. The majority of people would elect for as long a lifespan as possible (although we should not overestimate the appeal of longevity) and as little pain and disability as possible, yet they persist in behaviour which they acknowledge increases their chances of dying prematurely and of illness, pain, and disability; and they resist the passage of legislation which would make such behaviour more difficult. on
or
on
ROLE OF LANGUAGE
This paradox is, I propose, due to the linguistic framework on which people make such decisions. Their decisions are, in fact, rational within the limits of their linguistic framework, and the failure of preventive medicine is the result of a linguistic difficulty. I do not mean that the vocabulary used is incomprehensible. That may have been true at one time, but now the public is better educated and those who promote public health set out information in words which are familiar. Neither by linguistic do I mean semantic; the differences in meaning of the words, phrases, and sentences used by doctors
Reappraisal SOCIAL MEDICINE AND ITS CONTRIBUTION TO SOCIAL POLICY* F. M. MARTIN
University of Glasgow Department of Social Administration and Social Work, 53-57 Southpark Avenue, Glasgow G12 8LF
the Royal College of Psychiatrists. Was it a remarkable degree of psychological liberation, or mere naivete, that permitted the disclosure of so many anxieties, insecurities, and identity problems when the psychiatrists had to stake out their position in relation to general medicine? For social medicine, which has never had the advantage of actually treating patients, even of the wrong kind and with the wrong kinds of disease, the task of constructing an identity has been yet more difficult. The way in which a solution has been sought goes a long way to explaining why the social-policy contribution has been so
review of the achievements of the academic disciof pline social medicine over the years of its existence, one of the questions that must be asked is what has been the contribution of social medicine to social policy in general and to health-services policy in particular. There may be a doctoral thesis to be won by sieving through the products of academic social medicine in order to capture a few specimens of policy-oriented research, and by painfully reconstructing the relevant policy processes in order to show what part, if any, such research has played in their formulation. Yet it might well turn out to be the kind of research which involves the lavish use of bulldozers to demonstrate the fragility of eggshells. At the risk of being accused of cavalier over-generalisation, I would simply assert that academic social medicine’s contribution to policy has been small, and I would like to ask why this should have been so. No-one emerges particularly well from such an inquiry, neither doctors, In
nor
limited.
a
sociologists,
nor
policy-makers.
STAKING A CLAIM
Each
new discipline or sub-discipline has to make its in the academic or professional world, to define its way to identity, offer to its chosen audience some conception of what is- central and distinctive to itself. Almost invariably this has to be done within contexts constructed by already established professions and specialisms, and the task for the newcomer is largely one of locating itself within the often competing frames of reference which they provide. For a discipline coming within the ambit of medicine, the task of self-definition may require both intellectual agility and moral strength of a high order. The luminous prestige which attaches both to certain kinds of clinical excellence, and to a distinctive tradition
EPIDEMIOLOGY AND BEYOND
The pre-eminent concern of academic social medicine has unquestionably been the development of epidemiological methods and their application to the investigation of disease. Epidemiology involved direct access neither to the bedside nor to the laboratory; for the most part it took specific disease entities as its points of departure and could fairly claim to add a new dimension to clinical thinking. Any textbook of medicine could have, as it an epidemiological appendix to each chapter. That pursuit of epidemiological inquiries has added substantially to the advancement of medical knowledge is indisputable. It would be churlish even to question its right to the first rank among the contributions of academic social medicine. Yet the discipline has made no comparable intellectual investment either in the study of
were,
the
those processes which underlie the causal links identified in epidemiological studies, or in the detailed examination of the health-care implications of disease patterns. Those researchers who have with great care examined the role of smoking habits, dietary characteristics, alcohol intake, and other aspects of human behaviour in relation to various diseases, have tended to show little interest in the behavioural forms themselves, which stand no less urgently in need of investigation. Serious investigative work was required, for example, to pin down beyond dispute the connection between medication with thalidomide in early pregnancy and specific types of damage to the fetus. There were of course also some who paused to ask why it was that such huge numbers of pregnant women found it necessary to swallow so many tranquillising drugs; but I doubt whether anyone looked equally imaginatively for an answer.
of medicoscientific research, creates potentially crippling psychological difficulties for the new arrivals. Once the values associated with the established dominant specialties have entered deeply into one’s basic conception of what being a doctor means, it seems very difficult to establish an area of medical enterprise free from the magnetic fields of these values. For those medically qualified people who choose occupations where the relevant skills, knowledge, or subject-matter are remote from the concerns of the focal specialisms, building up identity and self-esteem is nearly always difficult. Psychiatry, unquestionably a clinical specialty, but with an atypical set of problems, concepts, and methods of investigation, is
interesting example. There is a fascinating analysis waiting to be carried out of the correspondence in the medical journals that preceded the decision to establish an
*Adapted from a paper given by Professor Martin at a symposium held by the Society for Social Medicine in Birmingham on Sept. 14 to mark the society’s 21st birthday.
PARTNERSHIP WITH THE SOCIAL SCIENCES
If there has been marked reluctance to enter the waters of motivation attitudes,’ culturally patterned behaviour and expectations, there has certainly been a greater readiness to examine systematically topics within the area of the provision and organisation of treatment and supportive services in response to healthcare needs. But these studies have not been carried out on such a scale, or at such a level of sophistication as epidemiological investigations, and have generally been regarded as fairly simple extensions of epidemiological inquiry, calling for few basic changes in conceptualisation or research method. We have rarely done justice to the multidimensional complexity of the planning, organisation, deployment, and utilisation of healthcare systems, and for that reason-among other powerful reasons, to be sure-we have had little impact on policy. To do this adequately would mean giving a
murky
1337 limited place to concepts and methods derived from medicine and statistics, and entering fully into a productive relationship with the social sciences-pretentious, verbose, and frequently confused though they are. Very few practitioners of social medicine have been prepared to hazard their medical identity to such an extent; and, perhaps more surprisingly, few have been able to achieve really effective working relationships with sociologists of comparable seniority. If we are to apportion responsibility, however, we must have regard not only to the over-caution of many physicians, but also to the irresponsibility of many sociologists. The relations between medicine and sociology could perhaps be likened to a marriage which had been based on false expectations and gone sadly wrong. Few would be misled by the male partner in the marriage-old Dr Medicine, kindly, benevolent, but a bit of a male chauvinist. He would be a decent enough husband, and his new bride would know her proper place and remain modestly within it. We can imagine his dismay when the little lady--or Ms Sociologia, as she insisted on being calledannounced that she was a dedicated member of an unspecified liberation movement, and intended to spend her time in marriage not in the academic equivalent of mending the old man’s socks and cooking his dinner, but in proclaiming the autonomy of sociology and denouncing medical domination. But metaphors apart, I think we may have been misled by a false analogy with statistics. Statistics has been a splendid ally to clinical medicine and epidemiology. The physician can go to a competent statistician and ask how statistical methods can be employed to find a solution to a particular problem, and the statistician will give an answer, even if it’s only that the problem isn’t soluble. To go to a sociologist with a similar request for help is to risk disappointment. What the sociologist may say is: "That’s an interesting problem, but before we think about answers can we look at it together and make quite sure that we’ve got it right? We want to be careful that we haven’t prejudged the issue, or written in any value-laden assumptions. There may be some components of the situation which have too readily been taken for granted, and perhaps need to be analysed explicitly". Such a response, capable of leading to a creative reformulation ot a problem, is positive and thoroughly professional. However, some doctors have found such a response difficult to accept, since it seemed to challenge their professional right to define issues and problems (although in fairness it must be said that it is very much easier now to engage in such dialogues than it was once). There is however another possible sociological response to the doctor who comes presenting a problem for solution. It runs roughly as follows: "Actually, I don’t think that’s an interesting problem at all, and I’m not in the least interested in solving it, because it would do nothing to advance sociological theory. Now, what I would really like to do is make a lot of taperecordings of doctors talking, and then write a fascinating paper analysing the peculiar processes that doctors go through in deciding what their problems are". The physician may well conclude that this is less than helpful. Sociologists of this persuasion, who complain that medical practitioners want to use them in a vulgarly instrumental way, must really not be surprised if they find themselves in deepening isolation.
RESEARCH AND POLICY
more
During the 1960s sociology in this country grew at a which perhaps outstripped the capacity of its roots to provide adequate intellectual nourishment; as a result some of its tendrils are blown about by every breeze of intellectual fashion. Between those for whom sociology
rate
is an instrument for fighting the class war, and those whose main allegiance is to ethnomethodology, it is sometimes difficult to discern the central core of theoretically informed and imaginative empirical research. It is there, of course, and in two or three centres medical sociologists have been doing research of a very high standard, even though the discipline’s overall achievements have fallen some way short of its potential. Contributions to policy, however, have not been far-reach-
ing. In the history of the relations between policy-makers and researchers in general, mutual misunderstandings and lost opportunities abound. The research community as a whole, when it has not turned its back on policy questions, has tended to have a naively simplified view of the policy process. It has felt aggrieved when the findings of research were not immediately incorporated in legislative or administrative measures, underestimating the part played by less rational forces-the activities of pressure groups, political and social ideologies, and, of course, sheer inertia-and striving for precision and clarity in policy-making where ambiguity and even inconsistency are inescapable. Policy-makers for their part are usually fairly clear about what’s wrong with research-it’s too late, it’s not relevant, the methods are crude, it doesn’t tell them what they want to know. But they also find it difficult to be specific about just what kind of research input into policy they positively want. It worries me that one of the few examples I can recall of a piece of research that was immediately and compre-
hensively incorporated into health-services policy was a thoroughly ill-conceived and misleading study-the 1961 prediction of changing mental-hospital occupancy rates, which really had nothing going for it apart from the self-confidence with which it was expressed. It is correspondingly depressing to contemplate the history of other changes in the health and related services, and to see how rarely research has influenced developments. It is hard, for example, to see what conceptual or research input went into the 1974 reorganisation of the National Health Service, apart from a few shreds from the rag-bag of management consultancy. And the crudity of most thinking on resource allocation is staggering. Then there are the policy questions that so far seem not to have been asked at all where the policy decisions are made-on how, for example, appropriate health care can be made usably available to members of socioeconomic groups whose inferior health own discipline has so fully documented.
status our
WORK TO BE DONE
Perhaps we should not draw pessimistic conclusions, and infer that good research can never find a receptive audience. However, there are some requirements which, for an effective contribution, must be fulfilled. First, policy-oriented research workers must understand the realities-the constraints and opportunities-of policy-making. Then a shift away from strong identification with a discipline, and from a strict allocation of work on
1338 human behaviour and organisation between established
disciplines,
is needed, though this is undoubtedly a difficult and almost threatening requirement, given the present structure of our professional and academic life. Finally, there should be a greater readiness to consider new research styles, with less emphasis on the formal long-term project, and more on studies which are constructed to allow for interchange between researcher and policymaker, and which can unashamedly change direction. All of these are hard demarids, and it would be surprising if more than a few workers were prepared to meet them. Some people may feel that it is unfair to criticise a discipline, even gently (and I know I have exaggerated), for the limited scale of its contribution in an area which many have not seen as really their pro-’ vince. But there is work to be done, work ofthe highest social importance; and it is up to those who are potentially the best qualified to do it-the members of the discipline of social ’medicine-to go ahead and seize the ’
.
opportunity.
THE FAILURE OF PREVENTIVE MEDICINE
J. A. MUIR GRAY Oxfordshire Area Health Authority (Teaching), Health Offices, Greyfriars, Paradise Street, Oxford OX1 1LE The failure to promote public health may be due, not to political or economic but to the fact that the arguments used to opposition, persuade people to change their behaviour or to agree to the passage of enabling legislation are set in a linguistic framework which has no meaning for them—namely, the concept of the future.
Summary
INTRODUCTION
ALTHOUGH preventive medicine has been widely accepted in principle, in practice progress has been very slow. Since the 1939-45 war, the only significant advances have been the development of comprehensive immunisation programmes, the Clean Air Act, and the legislation which made the wearing of crash helmets compulsory. There have been no sweeping measures, no Acts put on the Statute Book to compare with the Public Health Acts. Although "piecemeal social engineering" (the development of social policy by attacking individual problems rather than by attempting to create utopia by large-scale planning) is now, quite rightly, regarded as laudable, the small and hesitant steps taken to reduce the noxious effects of cigarette smoking, drinking and driving, driving without seatbelts, alcohol, and dietary imbalances, cannot be justified on the grounds that they are piecemeal. Epidemiology has revealed evidence that is at least as strong as that which led to massive changes in the 19th century and on which we could base policies to reduce the problems of cigarette smoking, road traffic accidents and problems caused by alcohol and dietary imbalance. Another disturbing aspect of the failure of preventive medicine is that the social-class differences in morbidity
and mortality appear to be widening and those personal preventive measures which are advocated by health educators have least impact on those most at risk-namely, people in social classes Iv and v.
WHY PREVENTIVE MEDICINE IS FAILING
One hypothesis rests on an economic premise-that the country "cannot afford" to act. This argument has been applied particularly to cigarettes and alcohol. However, an elegant analysis of the cost of cigarette smoking shows that it includes more than just the cost of treatment.Considering other costs, apart from treatment, there is a sound economic argument in support of increasing taxation on cigarette smoking; the same argument applies to problems related to alcohol abuse. In any case, if people did not spend their wealth on cigarettes or alcohol, they would have to dispose of it in some other way which the Treasury could tax to raise the same amount it now obtains from excise duty on tobacco and alcohol. Another hypothesis is based on a political premisethat politicians place a low priority on preventive medicine. The reason suggested is that the disease lobby, the movement to promote public health, is less powerful and less effective than lobbies which represent the financial and employment interests which would be adversely affected if measures were taken to prevent disease. The weakness of the disease lobby has been cited as the main In spite of reason for the success of the other lobbies. its failings, however, the profession is at last firmly behind preventive medicine. The reports of the Royal College of Physicians on smoking and fluoridation, the British Medical Association’s excellent work on road safety, and the activities of the Medical Council on Alcoholism and ASH (Action on Smoking and Health) indicate the strength of support, yet little action is taken. My inference is that politicians are slow and unwilling to act because they represent the people and reflect the public’s unwillingness to accept such legislation as that
random breath-testing, on restrictions on advertising, increased taxation on tobacco and alcohol. This is the paradox. The majority of people would elect for as long a lifespan as possible (although we should not overestimate the appeal of longevity) and as little pain and disability as possible, yet they persist in behaviour which they acknowledge increases their chances of dying prematurely and of illness, pain, and disability; and they resist the passage of legislation which would make such behaviour more difficult. on
or
on
ROLE OF LANGUAGE
This paradox is, I propose, due to the linguistic framework on which people make such decisions. Their decisions are, in fact, rational within the limits of their linguistic framework, and the failure of preventive medicine is the result of a linguistic difficulty. I do not mean that the vocabulary used is incomprehensible. That may have been true at one time, but now the public is better educated and those who promote public health set out information in words which are familiar. Neither by linguistic do I mean semantic; the differences in meaning of the words, phrases, and sentences used by doctors
