For 15 minutes I am supposed to chat about control of a disease, and blood tests and medications. The door is closed, and we can talk about tablets and blood tests, keeping the outside world at bay. Eventually, though, whatever happened in our consultation, we send the patient back to the environment they came from. For quite a few of our patients these environments contain the circumstances in which chronic diseases thrive.
We send them back to stressful jobs, or, even more stressful, lack of jobs. There may be no let-up at home, with the effects of long hours, low income, or poor housing all causing stress for families. The seeds of chronic disease take hold in these difficult circumstances, and germinate.1 For some people, the only relief they get comes in the form of cigarettes, alcohol, or comfort food, which is like fertiliser for chronic diseases.
In our consultations, naturally we concentrate on what we can change, and diet and smoking are frequently thought of as ‘lifestyle choices’. These choices are of course much more complicated than just healthy/unhealthy, and could be better characterised as ‘I’d love to but …’ The constraints on people’s ability to make decisions about their own lives are harder to see. The main one, though, is money.
For the most part, as doctors, we are in employment that, by most people’s standards, is well paid. Although we may feel a lack of control in our work lives, for most of us we have the financial means to have choices about where we live, the quality of our housing, and the food we buy. In our circumstances, chronic disease can take hold, but when these circumstances are absent they can thrive much more easily.
It’s so easy for policymakers — again, in reasonably well-paid employment — to imagine that everyone has the same degree of choice they do. People should ‘take responsibility’ and make decisions that benefit them, buying healthy food and stopping smoking. Then doctors can get on with prescribing the right medications, people can make the decision to follow our advice, and chronic disease is vanquished.
For too many people, these aren’t choices available to them. Fast-food outlets2 and cheaper, unhealthier supermarkets3 are more common in poorer communities, meaning healthy eating advice can be impractical and inconvenient. Taking control over your work life is risky for many people, with the rise of the gig economy leading to less power for workers if they actually want to be paid enough to eat and pay the rent. Even the wealthiest among us have no choice about the air that we breathe, and air pollution (even death) is more likely in areas where people have less money.4,5
And so we do what we can, with a hypoglycaemic agent here, a statin there, and hoping that antidepressants and psychology will get people through their social circumstances. Ultimately the circumstances that enable chronic diseases to thrive are found outside our consulting rooms and hospital wards.
Chronic diseases thrive where there is a lack of money and a lack of power. Of course we must continue to treat our individual patients, but we must also try to improve the circumstances in which people live, to allow them to thrive, rather than their diseases.
- © British Journal of General Practice 2018