Tuesday 26th July, 2005


Dr.David E Bratt MD

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Changing bad habits

A fairly compelling example of the close connection between government economic policy, business and health has just come out of Poland. This time, unlike the examples of the sales of cigarettes, alcohol and formula, it’s a positive and healthy relationship.

The former Eastern European communist countries have been having a difficult time making the transition from a centrally planned, directed and controlled economy to the freewheeling confusion of market forces.

In most of these countries, life expectancy, for example, has fallen in the past ten to 15 years. Most of this decrease has been due to coronary heart disease or heart attacks.

It had been thought that the transition would enable them to keep the only good thing about the communist health system: universal access to free healthcare, and lose the bad: authoritarianism, poor equipment, out-of-date training, lack of drugs and poor salaries.

Were it not for the lack of access to healthcare and poor salaries, that would be a penetrating and up-to-date description of our health service, ie, we’re neither here nor there. 

So many of their problems mirror ours. Corruption is endemic. Health managers are inexperienced. There are frequent changes of Ministers of Health, each one with their own ideas: one anti-doctor, the other a patcher (patch here, patch there), and yet another too timid to take any decisions.

In the midst of these challenges comes a success story. Poland has reduced deaths from coronary heart disease by over a third in the last 15 years, largely because of changes to their national diet. 

That’s like expecting Trinidadians to stop feting.

This has come at a time when many Polish doctors are emigrating to other European countries because of the poor conditions of employment, overwork, low salaries and difficulties in specialising because of authoritative and unwieldy systems dominated by older, senior and unmovable doctors.

It’s interesting then, though hardly surprising, that doctors have had little to do with this dramatic decrease in coronary mortality.

Trinis, with their “doctor going to save us attitude,” will be alarmed at that statement.

The decrease seems to be primarily due to changes in Polish economic policy that led to improvements in the population’s diet. Essentially, these included reducing subsidies for dairy and animal fats and subsidising fruits and vegetables instead.

The effect of these government policies was that, after the fall of communism in 1990, marked increases in the ratio of polyunsaturated fat to saturated fat in people’s diet was seen.

At the same time, with the opening up of the market to foreign forces, and the growth of the local fruit industry, supported by government policies, fruit consumption in Poland reached an all-time high and has continued to the present day. Fruits and vegetables are now available to consumers throughout the year.

Increased intakes of polyunsaturated fat also explain most of the major declines in coronary mortality in the United States, United Kingdom, and Australia over the last several decades.

It’s well known that fruits and vegetables have significant cardioprotective effects.

Despite initial resistance, no doubt from Polish men, the wider availability and lower prices for unsaturated fats and fruits and vegetables have caused rapid dietary changes. Housewives, like water, flow to lower and cheaper places.

During this period, as anyone who has travelled to Eastern Europe knows, despite intensive health promotion campaigns there has been no change in smoking habits, drinking patterns or exercise movements. Intensive health promotion campaigns have failed to dent the growth in consumption of alcohol and tobacco, which still enjoy liberal tax status.

Policies advocated by health ministries remain focused on medical models of education and behaviour change, even though these have had little impact on rising rates of unhealthy diets and obesity.

The message that emerges is that improvements in health cannot be expected from health reform or health promotion alone.

No amount of old talk from overweight doctors with a glass in one hand and a cigarette in the other can realise change. Real improvements in health have to come from a combination of health and political and economic reform. 

You can tell people ad nauseam what healthy choices are but unless you support them with tax incentives and make it easy for them to make those choices, it fails.

Is anyone in government reading or listening these days or is it true that governments save huge amounts of money when citizens die prematurely?




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