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
1339
by patients are now better recognised semantic problems remain a major barrier to (although I communication). hypothesise that it is the linguistic framework, the grammar, used by those people who wish to spread the ideas of preventive medicine which is the major obstacle to progress. My hypothesis is based on the research of Benjamin Lee Whorf, who was a linguist, as distinct from being a linguistic philosopher. Trained as a chemical engineer at the Massachusetts Institute of Technology, he became a linguist, studying in particular the languages of the Hopi Indians of Arizona. He compared the languages of the Hopis and their view of the world with those of people who spoke an Indo-European language, such as English. From his work came the appreciation that reality was subjective and was determined by the language, of the observer. He proposed a "new principle of relativity which holds that all observers are not led by the same physical evidence to the same picture of the
and those used
universe, unless their linguistic backgrounds
are
simi-
lar".2 I suggest that the main reason why people choose to act in a way that puts them at risk is because their concept of the future is different from that of those who give them advice. We ask people to desist from behaviour which is immediately rewarding, offering as an alternative a reduction in the probability that they will become unwell in the future, the future being a decade or more from the point at which the decision must be made. People in social classes iv and v, those most at risk, live and have been brought up in a culture in which time finishes next Friday. Job and house can be lost at the end of next week and savings can be spent in the first week or two of unemployment. There is an immediacy about working-class life which has been described most clearly by Prof. Richard Hoggart in The Uses of Liter-
acy.3 Although much has happened to increase the security of working-class life, the security of house and job, it probably takes generations to change a culture and the grammar which expresses it. A culture which embraces a concept of the future extending beyond next Friday is probably acquired informally in the teenage years by young people brought up in a family in which mort-
gages, insurances, and long-term planning imbue family life. The learning continues when the young person takes up an occupation and struggles to understand the problems associated with his own mortgage, insurance, and superannuation (there can be few more complex temporal concepts "than buying back extra years of
superannuation"). There are, of course, other factors which could explain the failure of preventive medicine. Sociologically, it may be that preventive medicine fails because it is projected by the middle class and is therefore rejected by the working class. Anthropologically, it may be that, because the public-health movement is based in the south of Britain, it is treated with little respect in the north. The linguistic hypothesis embraces both these factors. The basis of social classification is occupation; occupations in the higher social classes are more stable and more secure. The main factor distinguishing middleclass attitudes from those of the working class is their concept of the future, which is reflected in the different linguistic frameworks. Similarly, the great distinction
between North and South is linguistic. We are still two nations. In the South of Britain, the grammar has a future tense which is much more strongly developed than in the North. CONCLUSION
If
language barriers were to be adopted as a working hypothesis to explain the failure of preventive medicine, it would seem sensible to devolve health education. Great Britain has such a diverse cultural geography that national initiatives by the whole medical profession or the Health Education Council, although they have the authority of wisdom, lack complete credibility and should be complemented by locally produced material which reflects the local linguistic framework. Much greater involvement by the locals-housewives, pensioners, unemployed people, schoolchildren, and tradeunion members-is of great importance if an appropriate language is to be used. This applies both to "direct health education" which seeks to alter behaviour and "indirect health education" which seeks to alter attitudes to enable the passage of appropriate legislation. Although this hypothesis is difficult to test, the change in the way in which the consequences of cigarette smoking are presented (the fact emphasised is that cigarettes make one unattractive to kiss now rather than that they cause illness in ten or twenty years) shows that it has already been adopted by some health educators. I do not know whether it is possible to give an air of immediacy to the reasons for preventive medicine. I do say, however, that our inability to persuade people to adopt the means by which they can decrease the probability of illness, pain, and premature death requires a new approach to communication. It is not enough to ask people to postpone immediate gratification for the offer of a possible reward in an inconceivable future. I
am
G. M. ideas.
very grateful for the help of my wife, Miss A. Melia, Mr Blythe, and Mr J. H. Williams in the development of these
REFERENCES 1. 2.
Atkinson, A. B., Townsend, J. L. Lancet, 1977, ii, 492. Whorf, B. L. (1940) in Language, Thought and Reality: the collected writings of B. L. Whorf (edited by J. B. Carrol); p. 214. Massachusetts, 1956. 3. Hoggart, R. The Uses of Literacy; London, 1969.
Mahler, Director-General of the World Health in Dacca, Bangladesh, on Dec. 14 that declared Organisation, "we have signed the death certificate of smallpox in Asia". The commission of medical advisers from nine countries signed the final eradication certificate after studying the evidence of a two-year search for cases. "Make no mistake about it", Dr Mahler said, "this is the day of victory. It is here, on these densely populated plains, so often ravaged by flood, famine and war, that smallpox had its most ancient and tenancious roots ... After a huge effort, representing the total commitment of Bangladesh personnel and their partners from other countries, the last case of this, the most severe and crippling form of smallpox, was identified on Oct. 16, 1975." The results in Bangladesh opened the way to global abolition of smallpox vaccination by 1980. A final big push was needed in the Horn of Africa, particularly in Somalia, where the target was variola minor. The number of cases in the area had been steadily declining, and reached zero some weeks ago. But there were still many difficulties which hampered the eradication operations, and continued support was essential for complete success. Dr Halfdan
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
1339
by patients are now better recognised semantic problems remain a major barrier to (although I communication). hypothesise that it is the linguistic framework, the grammar, used by those people who wish to spread the ideas of preventive medicine which is the major obstacle to progress. My hypothesis is based on the research of Benjamin Lee Whorf, who was a linguist, as distinct from being a linguistic philosopher. Trained as a chemical engineer at the Massachusetts Institute of Technology, he became a linguist, studying in particular the languages of the Hopi Indians of Arizona. He compared the languages of the Hopis and their view of the world with those of people who spoke an Indo-European language, such as English. From his work came the appreciation that reality was subjective and was determined by the language, of the observer. He proposed a "new principle of relativity which holds that all observers are not led by the same physical evidence to the same picture of the
and those used
universe, unless their linguistic backgrounds
are
simi-
lar".2 I suggest that the main reason why people choose to act in a way that puts them at risk is because their concept of the future is different from that of those who give them advice. We ask people to desist from behaviour which is immediately rewarding, offering as an alternative a reduction in the probability that they will become unwell in the future, the future being a decade or more from the point at which the decision must be made. People in social classes iv and v, those most at risk, live and have been brought up in a culture in which time finishes next Friday. Job and house can be lost at the end of next week and savings can be spent in the first week or two of unemployment. There is an immediacy about working-class life which has been described most clearly by Prof. Richard Hoggart in The Uses of Liter-
acy.3 Although much has happened to increase the security of working-class life, the security of house and job, it probably takes generations to change a culture and the grammar which expresses it. A culture which embraces a concept of the future extending beyond next Friday is probably acquired informally in the teenage years by young people brought up in a family in which mort-
gages, insurances, and long-term planning imbue family life. The learning continues when the young person takes up an occupation and struggles to understand the problems associated with his own mortgage, insurance, and superannuation (there can be few more complex temporal concepts "than buying back extra years of
superannuation"). There are, of course, other factors which could explain the failure of preventive medicine. Sociologically, it may be that preventive medicine fails because it is projected by the middle class and is therefore rejected by the working class. Anthropologically, it may be that, because the public-health movement is based in the south of Britain, it is treated with little respect in the north. The linguistic hypothesis embraces both these factors. The basis of social classification is occupation; occupations in the higher social classes are more stable and more secure. The main factor distinguishing middleclass attitudes from those of the working class is their concept of the future, which is reflected in the different linguistic frameworks. Similarly, the great distinction
between North and South is linguistic. We are still two nations. In the South of Britain, the grammar has a future tense which is much more strongly developed than in the North. CONCLUSION
If
language barriers were to be adopted as a working hypothesis to explain the failure of preventive medicine, it would seem sensible to devolve health education. Great Britain has such a diverse cultural geography that national initiatives by the whole medical profession or the Health Education Council, although they have the authority of wisdom, lack complete credibility and should be complemented by locally produced material which reflects the local linguistic framework. Much greater involvement by the locals-housewives, pensioners, unemployed people, schoolchildren, and tradeunion members-is of great importance if an appropriate language is to be used. This applies both to "direct health education" which seeks to alter behaviour and "indirect health education" which seeks to alter attitudes to enable the passage of appropriate legislation. Although this hypothesis is difficult to test, the change in the way in which the consequences of cigarette smoking are presented (the fact emphasised is that cigarettes make one unattractive to kiss now rather than that they cause illness in ten or twenty years) shows that it has already been adopted by some health educators. I do not know whether it is possible to give an air of immediacy to the reasons for preventive medicine. I do say, however, that our inability to persuade people to adopt the means by which they can decrease the probability of illness, pain, and premature death requires a new approach to communication. It is not enough to ask people to postpone immediate gratification for the offer of a possible reward in an inconceivable future. I
am
G. M. ideas.
very grateful for the help of my wife, Miss A. Melia, Mr Blythe, and Mr J. H. Williams in the development of these
REFERENCES 1. 2.
Atkinson, A. B., Townsend, J. L. Lancet, 1977, ii, 492. Whorf, B. L. (1940) in Language, Thought and Reality: the collected writings of B. L. Whorf (edited by J. B. Carrol); p. 214. Massachusetts, 1956. 3. Hoggart, R. The Uses of Literacy; London, 1969.
Mahler, Director-General of the World Health in Dacca, Bangladesh, on Dec. 14 that declared Organisation, "we have signed the death certificate of smallpox in Asia". The commission of medical advisers from nine countries signed the final eradication certificate after studying the evidence of a two-year search for cases. "Make no mistake about it", Dr Mahler said, "this is the day of victory. It is here, on these densely populated plains, so often ravaged by flood, famine and war, that smallpox had its most ancient and tenancious roots ... After a huge effort, representing the total commitment of Bangladesh personnel and their partners from other countries, the last case of this, the most severe and crippling form of smallpox, was identified on Oct. 16, 1975." The results in Bangladesh opened the way to global abolition of smallpox vaccination by 1980. A final big push was needed in the Horn of Africa, particularly in Somalia, where the target was variola minor. The number of cases in the area had been steadily declining, and reached zero some weeks ago. But there were still many difficulties which hampered the eradication operations, and continued support was essential for complete success. Dr Halfdan
