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Like many of his fellow
citizens Toronto Mayor Mel Lastman didn’t know a lot about WHO until the
last few days, when its nature and powers became quite undeniably real and
frightening. But this bit of national ignorance, however understandable, is
completely unjustified for Canadians, of all people, ought to know what WHO
is like. This is because for over the last thirty years we - or at least the
people we trust our health care system to - have provided the intellectual
foundations for WHO’s approach not only to SARS in Toronto but much else.
And call if whatever you want - the boomerang effect, things bite back, or
reaping what you sow - the WHO we have helped to create has now come back to
haunt us.
Canada’s
most famous health export of the last 30 years has not been a break-through
understanding of a disease or a promising new therapy but rather the
intellectual musings of former Minister of Health Marc Lalonde.
Pick up
almost any national or international document on public health policy, or
prevention strategies, or a book on “health promotion” published anywhere in
the world and you will find a reference to the “Lalonde Doctrine”. And it is
the Lalonde Doctrine that is the driving force behind the WHO of 2003.
Lalonde
and his department, worried about the potential for unsustainable increases
in the cost of health care, believed that one answer was to focus more
resources not on the healing of diseases but on their prevention. And the
key to prevention, according to the dominant voices in the health community,
was changing lifestyles. The lifestyle recipe was straightforward: Canadians
needed to eat less, particularly of certain things, drink little if at all,
smoke nothing and exercise much more.
But if
the prescription was straightforward the means for getting the patient to
accept it were more complicated. Even in the 70’s the evidence about the
connection between lifestyles and the multifactoral diseases like cancer and
heart disease was debatable. The public was constantly being bombarded with
conflicting scientific information, whether about cholesterol, fat, coffee,
salt or any number of other alleged lifestyle culprits in ill-health. Last
year’s latest scientific truth about lifestyle and disease was quickly
overtaken by the newest and often contradictory medical pronouncements.
Then
too, Lalonde recognized that there was a strong streak of individualism in
Canadians with respect to their health. “It is not easy to get someone not
in pain to moderate insidious habits in the interests of future well-being”,
he noted. “The view that Canadians have the right ‘to choose their own
poison’is one that is strongly held.”
Lalonde
realized that if lifestyle medicine and with it prevention were to succeed,
two things had to happen. First, Canadians had to move from their view about
their right to live their lives as they pleased to one in which they
acknowledged a moral obligation to accept their society’s norm of healthy
behaviour, even if this meant abandoning some of life’s pleasures. Second,
the health establishment had to speak with one, clear, authoritative voice,
preferably if not a government voice at least a government-sanctioned voice
about the dangers of certain lifestyles.
This
meant that lifestyle change had to be vigourously promoted even if the
science supporting such changes was incomplete, ambigious and divided.
Taking his text from St. Paul’s first letter to the Corinthians, “If the
trumpet give an uncertain sound, who shall prepare himself to the battle”
Lalonde argued the careful scientific approach was unfitted to the task of
health promotion. “The spirit of enquiry and skepticism, and particularly
the Scientific Method… are … a problem in health promotion. The reason for
this is that science is full of ‘ ífs’ , ‘buts’, and maybes’ while messages
designed to influence the public must be loud, clear and unequivocal.”
However useful the integrity and skepticism of science might be in the
laboratory, in the political world that wanted to change lifestyles, or to
put it more bluntly- wanted to change the way in which whole nations thought
and lived- science often produced an “uncertain sound” that was decidedly
unhelpful.
Lalonde’s beliefs about the lifestyle and environmental sources of disease
quickly attracted international attention. His assumptions, goals and
implicit methods were adopted by WHO in its Alma Ata Declaration in 1977
which outlined a Health for All Strategy to be realized by the year 2000.
Toronto, ironically, provided the model for much of what the WHO wanted to
do, based on its Lalonde inspired mission statement to become the healthiest
city in North America by the year 2000. Aided by a process of secondments to
WHO from Health Canada and elsewhere, the health promotion mantra of
lifestyle medicine quickly came to dominate WHO’s institutional agenda.
Indeed, in Ottawa in 1986, much of Lalonde’s new perspective was officially
adopted by WHO in the Ottawa Charter for health promotion.
There
are at four dreadful consequences of this Canadian health promotion
contribution to the WHO. First, it is now routinely believed by most in
health care, in government, and in the world’s dominant health institution
that lifestyles demand intervention; that the way people live needs
changing. Central to Lalonde’s legacy is the conviction that health can be a
product of social engineering and that the paternalistic assaults on
autonomy implicit in this are not only justified in free societies but
required. Individuals, according to this doctrine are not often the best
judge of their own lives as they often require the better judgements of
their government to reorder not merely their values but their behaviours.
The nature of democratic citizens to think, speak and live with their own
voice is a merely messy impediment to the clarity of Lalonde’s trumpet and a
deadly distraction from the true WHO voice of healthy living.
Second,
for the heirs of Lalonde the scientific method is an impediment to healthy
living. Scientific methodology and rigour are a nuisance to health promotion
experts since so much that one knows is simply not true. Risk factor
epidemiology, not laboratory science, is after all the basis for lifestyle
medicine. Lifestyle junk science in which the scientific process as been
deeply corrupted becomes increasingly common. There is a poignancy in Dr.
Low asking the WHO for its evidence about SARS and Toronto, as if evidence
really had anything to do with WHO science. After all, it is the “Scientific
Method” that is the problem for health promotion and WHO. Once sound science
is considered non-essential for health, once scientific evidence is
disconnected from public health policy, then ends extrinsic to science, ends
that are often political drive the health care agenda. Whatever efficacy
lifestyle medicine might have is undercut but its own bad science.
Third,
ambiguity and uncertainty about health and lifestyle need to be suppressed.
Skeptics of the new lifestyle science must be shown to be nothing more than
the tools of some special interest. Since the public is not capable of
handling ifs, but, and maybe’s, truth-telling is less important than
effectiveness. We know that the evidence about fat and ill-health is often
equivocal, that blanket injunctions to eat less salt or take more exercise
provide little benefit, that overall there is no real cancer epidemic, that
there were many more people who contracted West Nile in Ontario last year
than we reported, and that SARS in Toronto has been confined to cases having
had contact with the health community, but taking the big picture into
account most of these things are not what the public needs to know. They
aren’t the “loud, clear and unequivocal” voice that is necessary to change
public behaviour.
One is
tempted to call this lying in the public health interest but this is
probably stretching the truth. As one exponent of lifestyle medicine put it
so well in Discover magazine: “…Scientists should consider stretching the
truth to get some broad base support, to capture the public’s imagination.
That, entails getting loads of media coverage. So we have to offer up scary
scenarios, make simplified, dramatic statements, and make little mention
about any doubts we might have…. Each of us has to decide what the right
balance is between being effective and being honest.” Marc Lalonde and WHO
could not have put it better themselves.
Fourth,
instead of concentrating on the genuine health problems plaguing most of the
world’s population, like the 300 million people suffering from malaria (
roughly 2500 of whom die each day), the heirs of Lalonde at WHO are more
concerned about a collection of scientifically suspect, and in some instance
trivial pursuits of lifestyle medicine. Included in the WHO agenda for
instance is fighting the “ proliferation of sugary, fatty and salty food”
through advertising restrictions or sin taxes, reducing the “epidemic”of
alcohol consumption through new control measures like advertising bans,
redefining good health to include “spiritual well-being” along with ways to
promote it ( one wonders where the world’s atheists fit in this definition
of good health) and making certain that primary health care systems are
“based on cooperation and teamwork.” Nowhere in its massively oversized
bureaucracy is there anyone at WHO who appears to realize that its
preoccupation with lifestyle medicine might represent not only an
insensitive medical imperialism in which the health agenda of the first
world dominates and is thoughtlessly exported to the rest of the world, but
a dangerous neglect of problems that matter desperately to several billion
people.
About
the only good thing to come out of Toronto’s battle with SARS is that it
might just have awakened Canadians from their dangerous ignorance about WHO
and alerted them to the quite real dangers in so much of what WHO is about.
A WHO modeled on the musings of a Canadian health minister some 30 years ago
is the arrogant WHO of today whose reaction to SARS in Toronto and whose
shortcomings in the face of a real as opposed to a lifestyle disease is in
part our own sad legacy.
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CANADIAN CONTENT AT WHO
