Maybe it’s not you, it’s the water

The best soccer teams never let the ball get to the goalie, and the healthiest goldfish still need their water changed. These were the central themes of Dr Sandro Galea‘s speech Thursday at the Canadian Society for Epidemiology and Biostatistics’s national conference in Winnipeg.

The talk highlighted the over-focus on tiny, proximal parts of an overall chain of events leading to disease. By now we have learned everything from eating nuts to vitamins to swimming prevents cancer, for instance. We have also made mass investment into personalized medicine, taking tailored health to a new level.  The message is clearer than ever: health is experienced by the individual so it must be in the individual’s hands.

At the same time, most of us are grounded in an overall interest to improve population health. By focusing on the determinants of health at an ever-increasing individual level, we ignore the systems and environment within which people make health decisions. For instance, there has been a major decline in automobile accidents over the past century. What is responsible? Safer roads and safer cars.  Not focusing on the individual driver’s abilities. Similarly, having a population impact requires a perspective on the conditions under which we can learn to eat more nuts and vitamins, and buy more swimming pool memberships.

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Our own Sofia asking Dr Galea a question

According to  Dr. Galea, the solution centers on a re-calibration of time and monetary investment. This does not involve spending more time and money, but pulling existing research energy and health system funding towards evidence on population options and public health infrastructure. The ‘no net increase in spending’ argument should win over politicians who may be completely unaware of this perspective; lately, funding has gone the opposite way (while interesting in theory,  imagine the public reaction to the headline, “Funding cuts to hospitals,” regardless of the overall benefit).

Ultimately a population approach stops people from getting sick in the first place: it is all the offense and defense in place before the ball ever gets to the goalie.  It also acknowledges the limits of individual responsibility: a goldfish eating the healthiest and exercising the most can only go so far in murky water.   While we still need a goalie when we get sick, and we still need to look after ourselves, stressing only individual health determinants hinders fulfilling what most of us would like to see: better population health.