James Watson said in the Double Helix, his account of the discovery of DNA, "Science seldom proceeds in the straightforward logical manner imagined by outsiders. Instead, its steps forward (and sometimes back ward) are often very human events in which personalities and cultural traditions play major roles." Science and art are not easily separated, in fact health promotion science without health promotion art is like a physician without a bedside manner, ....or a surgeon without a golf handicap.
I'd like to do a little evidence-based marketing for health promotion. I will examine the view that, just like good medicine, good health promotion not only requires good science but it also yearns for good art.
Now, science, as we know, is the "systematic study of the nature and behaviour of the material and physical universe based on observation, experimentation and measurement. It provides us with an understanding of the scope, frequency and determinants of disease and health behaviours, and gives us the knowledge to build systems, services, communications, laws and regulations.
Art is the 'exercise of human skill, the skill governing a particular human activity'. This encompasses advocacy, communication, shaping public opinion, constituency building, and information dissemination.
Successful health promotion relies on the art of putting new ideas into action, and, as importantly, applying what is already known. Even if there were no new scientific breakthroughs for another ten years we could still easily reduce premature death considerably through what is the core art of public health - advocacy. Take tobacco control - to move from a prevalence of 25% of smokers in the general population to 15% requires just as much art as science. In Kenya and Zimbabwe new science in HIV prevention is not needed in the short term. What is needed is the art to develop the political will to acknowledge the reality of sexual behaviour and confront it honestly and realistically. Unless Daniel Arap Moi and Robert Mugabe take the issue of AIDS seriously, and they should given that 25% of the adult is infected with HIV then little impact can occur.
The recipe for good public health and health promotion require both ingredients - good science and good art. They are complementary.
It started with John Snow an English General Practitioner. He worked in a London suburb, where in 1854 five hundred people had died of cholera in ten days, - not an unusual occurrence at that time. What was unusual about that outbreak was that Snow went beyond examining individual patients and looked at the outbreak at the level of the public health. He stepped out of the office, past the scores of waiting patients, and walked down Broad St.
He looked at the map of incidence of cholera, noted that there seemed to be a concentration of cases along Broad Street, hypothesised that cholera was a water-borne disease, and determined that many patients must be drinking contaminated water from the Broad Street pump. So he went out, took the handle off the pump, and provided the foundation myth of the public health movement and of health promotion.
We see here an example of good science being combined with the art of creative action to produce an effective result.
I would like to examine several recent health promotion successes that have employed both art and science, - these successes include tobacco control, reduction of road trauma, HIV/AIDS control and skin cancer prevention. I will present the key steps for successful health promotion. And I will examine what lessons we can draw from past experience - so we can more effectively approach two issues that will keep us talking well into the new millennium - illicit drug use and obesity.
In 1991 the Medical Benefits Fund of Australia (MBF) used Rembrandt's Bathsheba in their Breast Health public relations campaign which aimed to raise awareness of the importance of screening mammograms for women over forty.
The painting starred in a public awareness campaign which illustrates perfectly (and literally) how art and science can work in unison for a successful health promotion outcome.
The painting depicts Rembrandt's common law wife with what is now known to be advanced breast cancer - dimpling and darkening of the left breast.
The campaign resulted in the Breast Clinic Information Line receiving 2500 calls within the ten days from the programmes launch, and a 700 per cent rise in calls for clinic appointments.
Good health promotion is powerful and effective. Some examples include:
- Smoking rates have dropped from 75% in men in the 1950s to 22% now. Consumption of cigarettes has dropped in Australia over the last 20 years, so much so that some tobacco company executives now receive bonuses if they stop sales dropping.
- On Victorian roads every year there are 650 fewer people dying and 6,000 less people being severely injured compared to the early 1970s.
- In the mid 1980s over 2300 new infections of HIV were occurring every year in Australia. This is now less than 600 per year.
- The rate of Sudden Infant Death Syndrome has dropped over 60% from 300 per 100,000 live male births in 1987 to less than 100 per 100,000 in 1996.
- Public health has even changed our perception of beauty.
I was a lifesaver at Jan Juc in the late 60s - performing as we all did the annual ritual of baking so we could be bronzed Aussies. Now to see lifesavers with wide brimmed hats, sun cream and long sleeved T shirts is quite remarkable. As a result of setting examples such as this, and heightened awareness through education campaigns, our risk of skin cancer is declining. Between 1985 and 1995, basal cell carcinoma decreased by over 20% in 14-39 year olds, and melanoma incidence has decreased for the first time in men and women.
And health promotion is not only powerful and effective, but cheap too!
- Smoking prevention costs per life year gained less than 1/500th of the costs of treating lung cancer.
- Since 1989, the Transport Accident Commission has saved in excess of $1 billion through reduced claims payouts, and overall has saved the Victorian community more than $2.9 billion.
- The direct cost of treatment for skin cancer in Australia is $8.7 per head per annum, compared to prevention costs of only 12cents per head per annum.
- The cost of treating a man with AIDS between 1989-1993 was $46,500 per life year saved compared to $185 per year of life saved for education and prevention.
The World Bank in its 1993 landmark report, Investing in Health, stated that 'many governments spend far too much on sophisticated hospital services of low cost effectiveness and too little on essential public health and clinical services'.
So, to briefly recap - we have seen what health promotion is. We have seen that successful health promotion requires both art and science. And we have seen the benefits of good health promotion - it is powerful, effective and cost-efficient.
But what are the essential steps to ensure successful public health?
There are six main components of successful health promotion.
I will explain what I mean by each of these necessary steps, and then outline some concrete examples where each of these factors have combined to produce a successful result.
Establish a system for intelligence gathering
Good science must underpin good health promotion. This requires data to describe the scope and distribution of the problem, fundamental public health research to understand the determinants of the problem, data to monitor the progress of interventions, and evaluation to measure the effectiveness of the interventions.
Develop clear policy, legislation and regulation
Policy determines the overall thrust of health promotion. It is the engine for change. Legislation and regulation have to support the desired outcomes of policy. If they do not, as we will see later in the case of illicit drugs, then conflict arises and the policy outcomes simply cannot be achieved. And it can be policy, legislation and regulation well outside the health sector that can have the most impact on health, such as the regulation of the sale and pricing of alcohol, tobacco and food, or tax incentives to encourage travel on public transport, or for business to invest in rural areas or construction of bike paths.
Legislation is however a social activity, not a laboratory protocol. It involves getting politicians on-side, and involving stakeholders, negotiating trades-off, compromises and divisions of responsibility, to get new or changed legislation through the bureaucracy, through the Parliament and through the bureaucracy again. There are no algorithms that will guarantee success at these tasks. The kind of description that explains these things, the kind of analysis that helps, is completely different - it is qualitative, social, historical, and personal.
Communicate the information
There is the evidence, then policy and legislation, and then the need to know. One of our fundamental human rights is the right to know - to be informed about the scope of health problems, the risks we are exposed to, the protective behaviours we need to adopt, and where we can access services.
And we often need reminding. This is art as well as science and continual reinforcement of messages help us in cultural shifts of attitudes and behaviours as I mentioned before about suntans. In addition, communications must be targeted at groups with specific information needs, and to those most vulnerable.
Provide the services and educate the Workforce
Then there are the systems and services to put these policies into practice, and to encourage people to modify their behaviour and enable them to make healthy choices. This one of the easiest elements of successful health promotion to conceive, but the most difficult to implement.
Share responsibility across sectors
And these systems and services must be intersectoral. We might call it "health" promotion but the health sector cannot go it alone. So much of what makes you sick or healthy actually lies outside the health sector. How much you earn, your social position, your level of literacy, your culture and the political system you live in all determine your health, so the responsibility for public health has to be shared by other sectors of society.
Next, just as policy gives direction from 'top down', effective health promotion requires 'bottom up' involvement, participation and direction by the people most affected by the issue.
Former President Ramos of the Philippines borrows a local metaphor about the way bibingka, a kind of rice cake is prepared. Bibingka is baked in a clay oven, with heat applied from the bottom and from the top. Skilled bibingka makers have to learn how to apply the heat evenly. In talking about HIV/AIDS he said so often programmes fail because of the lack of art - the lack of even heat.And these elements have to be synergistic. By this I mean that each strategy helps the others. Leave one out and you weaken the whole approach. For example wonderful communications without the legislation and services to back up the messages become a waste of time.
I will now outline some case studies where we can see how each of these elements contributed to produce a successful outcome.
VicHealth has been a major backer of the Anti Cancer Council of Victoria's Quit Campaign over the last 12 years.
As a result of the excellent work done by Dr David Hill and his team at the Centre for Behavioural Research in Cancer we now have regular data covering prevalence levels of smoking, tracking of state and national campaigns, evaluation of the effects of health warnings, levels of environmental tobacco smoke, beliefs and attitudes in minority communities, and so on.
The state legislation to create Vic Health and to buy cigarette sponsorship out of the sports and arts and replace them with health promotion messages was followed by federal legislation to ban cigarette advertising in all but a few events.
Communications such as those seen in the slides and the more recent "Every cigarette is doing damage" campaign have been repeated and consistent. as has the Smokefree sponsorship of sport such as elite level and junior football development. These communications are supported by services to those who want to quit, and a whole range of community activities.
Over the last ten years a very sophisticated system of data collection has been developed by the Transport Accident Commission and the Victorian Police - this includes data on fatality rates, morbidity, black spots, data from speed cameras, breathalyser testing, driver attitudes, and so on. Good analyses have shown that alcohol, speed and fatigue are the big three causes of road trauma.
A classic change of legislation was the compulsory wearing of seat belts, in addition to significant penalties for speeding and drunk driving.
The systems and services provided include speed cameras, boose buses, the police to support them, and safer roads. By the way who has been breathalysed in the last year?
Most of you will recall the 'If you drink and drive you're a bloody idiot', 'Speed kills' and 'Fatigue kills' campaigns. They have also developed many targeted campaigns such as this one aimed at those taking drugs and driving.
The benefits in reduced TAC payments outweighs cost of these advertising campaigns by between 4-8 times. And the road trauma work has involves the police, the courts, VicRoads, local government and car engineers and manufacturers, as well as the health sector. In addition hundreds of local communities have their established their own road safety associations.
Before coming to VicHealth I was working with UNAIDS, the joint UN programme on HIV/AIDS, and was responsible for setting up this new programme in over 120 countries. So I was fortunate to be able to see at first hand where HIV is successfully dealt with and where it isn't. Without doubt the defining characteristic of successful approaches to HIV is the mobilisation and inclusion of communities, affected and infected by the virus.
Whether it is gay men in Australia , sex workers in Thailand or whole communities in Uganda, the same principle applies - people living with HIV or most at risk are the ones that end up initiating and underpinning effective responses. One of the best examples is the AIDS Support Organisation of Uganda, TASO. It was started by one of the most inspiring people I have ever met - Noreen Kaleeba. It has mobilised community, national and international commitment. In a poor country it has mobilised thousands of villagers and urban dwellers for the prevention and care of HIV. So much so that young women in urban areas have 40% less chance of being infected with HIV compared to 4 or 5 years ago.
At the same time legislation to support rights to information and care and to maintain freedom from discrimination for people with or at risk of becoming infected with HIV has been essential in creating safe and supportive environments for people to change behaviour and maintain the change.
Communications campaigns date back to the Grim Reaper campaign, and have been often targeted to those at higher risk.
The legislation and communications have been underpinned by access to counselling and testing, diagnosis and treatment of other sexually transmitted diseases, particularly for those that are most vulnerable, as well the physical and emotional care for people who are HIV positive.
And effective HIV/AIDS control involves education, the private sector, labour unions, the media, welfare, defence forces, prison authorities, seafarers, - health cannot go it alone
Skin Cancer prevention
The Sun Smart Campaign has been based on sound evidence which contributes to an understanding of the attitudes and behaviours of Victorians. Data on weekend sunburn rates, on beliefs and sun shade practices, on levels of skin cancers are being continually collected to evaluate the effectiveness of the programme. One startling figure is that weekend sunburn sates have declined by 60% in Victoria since 1988.
The evidence has driven the development of a long term and highly successful 'Slip Slop Slap' communications campaign. In Victoria, the success of skin cancer prevention has relied on the mobilisation of schools and sporting clubs such as life savers. As a result of sponsorship provided by VicHealth through the Sun Smart Campaign, Victorian life savers have much greater sun protective behaviour than their NSW counterparts where no such sponsorship occurs. The Victorians wear broad brimmed hats and long sleeve T-shirts much more often, and not surprisingly suffer much less sunburn.
Schools have changed policy to insist on children wearing protective hats and providing sun shade areas. Lets look at the art of health promotion a little more closely.
In each of the cases discussed tonight it has been the persistent, vocal and often courageous work of individuals and groups. It involves the combination of convincing science, timing, community support, public opinion, building coalitions of decision makers, political champions, campaign strategies, persistence and good tactics.
And it is important to identify the enemy. This is art. For example, with smoking the enemy isn't smokers, nor the government, nor other anti tobacco groups who have a slightly different viewpoint to yours. It is definitely the tobacco companies. Some of you will have read of Professor Stan Glantz a leading Californian anti tobacco advocate who recently was here suggesting we had lost our focus on the tobacco companies. Remember that in Australia tobacco is the number one killer, responsible for 18,000 premature deaths each year. And the tobacco companies who operate in Australia are also seeking markets all over the developing world.
Listen to one of these quotes...
" Marlboro's marketing strategy 1990 23% of the population is 15 years of age and under. 17% is 16-24 years of age. Given predisposition to try [or] adopt new brands, this segment represents significant market opportunity....Overall objective: position Marlboro as a 'cult' brand -- to attract new smokers".
And they knew it caused cancer and that it was addictive.
Do these companies really work in the public interest?
One of the most effective global advocates was Jim Grant, the late Director of UNICEF. Every where he went he would carry packets of oral rehydration salts, and no matter whom he was with, presidents or popes or paupers, he would bring them out and push the point. His art in advocacy also resulted in him bringing together more heads of state than ever before to sign the Declaration on the Rights of the Child.
In a different field but equally as persuasive is Khun Mechai Viravaidya of Thailand, who is constantly reminds Thailand and the rest of us the importance of condoms - even to the point of creating a chain of successful Cabbages and Condoms restaurants.
But alas it is often poor art (otherwise known as politics) that causes the problems in the first place. Take for example refugee health - and the misery we have in Kosovo and Albania and in so many other parts of the world. But given that these situations have occurred throughout history and will occur again how can we make the best of a bad situation. And here the science and the art of refugee health has improved dramatically over the last twenty years - through the work of agencies such as Medicins Sans Frontieres and Save the Children Fund and individuals such as Mike Toole, from MBC. By assuring sufficient food, clean water and immunisation such as measles death rates in such difficult circumstances can be reduced significantly.
Let us go back to our key elements of successful health promotion. Given these, how are we doing with two of the 'big ticket' issues for the next century? And I refer to illicit drugs and obesity.
We are making some inroads into this problem but there is still a lot of work to be done. In Victoria the drug death toll nearly mirrors the state road toll. What about the evidence? What don't we know - there is much missing information on the number of users, types of drugs, pricing of drugs, and modes of initiation.
What about the policy? We do not yet have an agreed upon overarching policy. On the one hand we have our Prime Minister advocating a zero tolerance approach, and on the other hand so many in the field including state premiers, commissioners of police, local government officials and expert researchers and practitioners who advocate viewing drug as a health issue, not as a criminal issue. The US's zero tolerance approach has filled its gaols with drug users - no doubt one of the most efficient ways to perpetuate the drug problem. Surely we can learn that we need a new approach when drug overdoses are expected to rise by two hundred percent and when drug overdose deaths even occur in prison. In 1995 in the Netherlands, where they view drugs as a health issues there were 37 drug related deaths compared to Australia's 634. The irony of the latter figure is that it came from an address by the Prime Minister entitled 'Tough on Drugs".
Current legislation and regulation provide enormous financial incentives to produce and export or import more and more drugs. As the recent VicHealth funded study by John Fitzgerald into the drug situation in Fitzroy and Collingwood pointed out, the drug trade is the most deregulated market in Australia. As David Stanley from the Australian Drug Law Reform Foundation has pointed out it is easier for a 15 year old to score heroin in Cabramatta than to buy a can of beer.
Just as we have moved homelessness and alcoholism out of the criminal system, so must we act with other drug use. We must not only deal with the 'end issue' of drug overdoses but also deal with the societal and structural issues that lead to increasing drug use.
This is why VicHealth has commenced the first state-wide mental health promotion strategy to focus on ways to improve individual as well as collective emotional health to improve family relationships, productivity at school and at the workplace.
Our communications and education programmes for drug use have to be targeted to the different audiences. Messages for primary school students must be different for those who have already been exposed to drugs and from those already using them, or for the parents of drug users.
We must develop services for users, such as education, counselling, needle and syringe exchanges, testing of purity of drugs, referral for treatment, and medical/nursing supervision of injecting.
But it is perhaps the art as much as the science that is lacking. The art of generating our collective capacity to acknowledge reality as it is, not as we might wish it to be. - And dealing honestly with the reality, not burying our heads in the sand.
Another major health promotion challenge is obesity. As we head into the next century, we are a 'growing' society. Levels of obesity are rising for both women and men, and for children.
Look at these figures from the US for young children, provided by Professor Keren O'Dea, these figures approximate the situation in Australia.
For the first time in human history children are becoming sedentary. It is our incidental activity that is diminishing, the activity that we use to carry out our daily living. Technology has reduced the need for us to exercise, to use calories. Car from home to office, remote control to operate appliances at home, out-sourcing menial but energy expending tasks at home and the ultimate irony - the need to compensate our lack of incidental energy by concentrated exercise. Soon life will be virtual - no need to go walking - you'll be able to do it on a treadmill at home surrounded by your 360 degree picture of the world outside the house.
Another case in point is the high degree of association between television watching and obesity in children, as seen in this slide. Is say throw away the remote control and bring back the knob on the television, better still have 'pedal television' - it both reduces the amount of television watched and reduces obesity.
To say that we have some policy and legislative challenges ahead of us is to almost belittle the problem. We will need a profoundly different response in our adaptation (mall-adaptation) to technological change.
Challenges for the future
What of the other challenges in health promotion in Australia? As health care becomes more expensive, as more of the health dollar is spent on the last years of our lives, what should we do?
Well I guess it is clear that I would devote much more of the health dollar to good buys in health promotion. But that also requires moving funds form the acute sector - from money that might be spent on your or my hospitalisation in a time of crises.
Firstly we must start to link prevention to those that pay the bills. One of the best examples of this (and incidentally one of the best health promotion initiatives ever taken in Victoria) is the Transport Accident Commission. The organisation that pays the bills for treatment also pays for the prevention - and when the prevention works it cuts costs and reinforces the willingness of the TAC to invest in prevention. In Germany the new privatised health insurance bodies are required by law to spend 1% of their funds on public health. Perhaps we can get our private health insurers and the Health Insurance Commission to do the same in Australia.
Increasingly we will have to link socially desirable with economically desirable outcomes, to develop synergies between sectors. An example - if we look at encouraging more people on the public transport system - this has benefits for the transport sectors profits, for the environment, with a reduction in car emissions and for the health of individuals themselves, as they expend far more energy than driving to work or school.
Perhaps the major challenge is to ensure that the health gains are made by all sections of society not only by those who are economically and socially better off. Many of the major determinants of health, such as employment, income, literacy, level of community services, discrimination in its different forms such as racism, sexism and ageism lie outside the health sector.
Death rates for the most disadvantaged fifth of our population are 50% higher for boys 0-14 years and 68% higher for adult men compared to the wealthiest 20%.
There is a current surge of interest in research in this area in Australia - both through the Federal and State governments and in many academic departments - but the challenge remains a daunting one.
And to conclude it is important to recognise that good art and science are driven by people - people with passion and compassion. In particular, the art of public health is driven by people of conviction and commitment such as Noreen Kaleeba from Uganda, Nigel Gray, one of the pioneers in tobacco control in Victoria.
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2 Woodward S personal communication
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4 World Health Organisation. Tobacco Epidemic. Much more than a Health Issue. Fact Sheet No 155, 1998
5 Transport Accident Commission Community Savings
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7 World Bank Investing in Health. World Development Report 1993. P65. Oxford University Press.
8 From Words to Action. Report of the 4th International Congress on AIDS in Asia and the Pacific. Manila 1998
9 NHMRC 1995
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11 European Drug Monitoring Service
12 Australian Institute of Health and Welfare