Feature

Cold hearts and coronaries

Campaigns to combat heart disease ask us to change the way we live our lives. Instead, they should attempt to change the world we live in, says Sonja Hunt

large number of people currently employed in health promotion have to promote campaigns and activities which do not address the fundamental health problems in this country. Political pressure from the government, filtered through health authorities, is forcing many workers to spend most of their time trying to balance political expediency with sensitivity to public need.

A century ago, the early public health reformers were well aware that the basic requirements for a healthy population were warm, dry shelter, clean air and water, affordable nutritious and sufficient food and an adequate income. In the last 15 years we have seen the gradual erosion of these basic needs, increasing homelessness, frightening levels of pollutants in the air and in drinking water, and increasing food prices and declining incomes for the less affluent sections of this ‘classless’ society.

At the same time there has been a deliberate attempt to persuade the population that they have the main responsibility for their own health. There is very little that we can now do which is not attended by fear of death or disease or shadowed by guilt, whether it is going to the pub, having chips for tea or relaxing with a cigarette. There have been a few public voices raised against this ‘victim-blaming’.

Political ideologies have come to dominate the delivery of health services and the tenor of health education in a quite unprecedented way, distorting the picture of public health and creating a climate in which informed people are afraid to speak out against what they know to be wrong.

Current campaigns supposedly aimed at the reduction of coronary heart disease illustrate some of the dilemmas which face those working in health promotion. These are: targeting disease or focusing on health; being concerned with quantity of life or quality of life; serving political masters or public need.

Attempts to reduce coronary heart disease by the strategies typically adopted in the past 15 years, that is by attacking ‘lifestyles’, are misguided and ill-informed at best and unethical, cruel and cynical at worst.

There are well laid down criteria for campaigns aimed at the prevention of disease. These are that: the medical condition should be well-defined; the cause of the condition is known; appropriate intervention exists; compliance with control strategies is likely to be substantial.

None of these criteria are fulfilled in the case of coronary heart disease, which is neither well defined nor well understood. The diagnosis is a consequence of changing fashions in medical classification and came into existence only just prior to the Second World War. It covers a variety of problems involving respiratory organs and peripheral vessels as well as the heart itself. The cause of heart disease is unknown, although there are several ‘risk factors’, most of which are beyond individual control.

Few people understand that these risk factors are based upon statistical probabilities for the population as a whole or that their applicability to any one individual is highly uncertain. Moreover, reviews of combined research in the US have shown that over a 10 year period, only about 10 per cent of men with two risk factors do go on to develop heart disease. Of those men who did develop coronary heart disease, 58 per cent had only one of the assumed risk factors or none at all.

It follows that appropriate intervention strategies are unknown. Those that have been tried have not shown notable success and the level of compliance with the prescriptions of health education is highly variable across groups, often short-lived and subject to misreporting for reasons of social acceptability.

The focus on individual behaviour as the major cause of death from heart disease cannot be supported by scientific evidence. But it is politically useful, acceptable to the medical profession and easy to grasp. In relation to diet, for example, the picture of fatty foods clogging up arteries as if they were drains has an instant if unpleasant appeal. Unfortunately it is totally inaccurate, based as it is upon a misunderstanding of the operation of the digestive system. The latest research suggests that a low fat diet may be more harmful, since polyunsaturates oxidise more quickly and may result in thickening and scarring of arterial walls. A low fat diet is known to impair the physical development of children. Moreover, areas where the population has a high fat intake, such as Crete and the Netherlands, actually have a relatively low incidence of heart disease and a long life expectancy. Greece has one of the longest life expectancies in the Western world although smoking rates are among the highest. As for exercise, there is no evidence to show that exercising regularly staves off heart disease because it is impossible to conduct controlled experiments.

The link between certain factors associated with the risk of developing heart disease and death from heart disease is composed of a separate set of possibilities. There are several stages leading up to death: predisposing factors, present from before or soon after birth, such as family history or infections in infancy; factors which increase susceptibility, such as economic and social strain, stress, smoking; factors which may precipitate a heart attack, such as accumulated stress, unemployment, a traumatic event; and factors which increase the likelihood of dying from an attack, such as social isolation, financial problems and speed of treatment.

There is no simple chain of events, where cause and effect are clear cut. Rather, heart disease mortality is a complex sociological phenomenon in which both political ideology and the dominance of clinical medicine play a major role in determining our view of reality.

The way we have been taught to construe heart disease has been influenced by a medical model which teaches that the target of treatment should be the individual. This approach may more or less work in relation to treatment but it is certainly less appropriate in respect of prevention, because it ignores the fact that ill-health is principally a group phenomenon.

It seems that certain disadvantaged groups in society become more vulnerable than others to a wide variety of breakdowns in health. This strongly supports a model of general susceptibility in which disease is a consequence of some groups being assailed by a set of strains associated with disadvantages at work, at home and in the wider environment. Whether individuals belonging to these groups will become heartsick or soulsick will depend upon a host of other background factors.

Targeting a medical condition of largely unknown and complex aetiology is expensive, ineffective and, some would argue, unethical. Moreover, it is cruel to expose people to conditions which make them ill and then blame them for dying. It is immoral to promise what cannot be delivered and to make people unnecessarily anxious in the interests of diverting attention from the fundamental inequalities which determine patterns of health and disease in this country.

Concern with quantity of life is distracting attention from quality of life. Far too many people live under conditions which make them frustrated, angry, dispirited, hopeless and disheartened. Heart disease is just one of many manifestations of the unequal distribution of resources in our society.

There is something seriously wrong with a society in which homelessness, poverty and racism are tolerated, even seen as normal, while smoking is regarded with horror. Smoking may well be an obnoxious habit but it is not nearly as harmful as sleeping in the street or a crowded bed and breakfast, living in constant debt in a cold damp house, going daily in fear of insult or assault, or facing a future devoid of dignity and respect.

There is also a certain anti-life element to the more self-righteous strictures of the self-appointed guardians of the public health. It is important to remember that the risk of death is increased by many things — war, traffic, high winds and jogging, for example. We were not designed for immortality and will inevitably die. Should life not then be enjoyable as far as is compatible with the human condition? As Margaret Drabble once wrote: ‘The prudent are admirable but rarely attractive.’

There are worse states than a heart disease — a cold heart, for one, or worse, being totally heartless. Perhaps future Look after your heart campaigns should be directed at those individuals in positions of power nationally and locally whose heartlessness continues to damage the nation’s health.