by Dr Ishma Harford
Public Health approaches to tackling stress in the population begin with lofty ambitions.
A systems perspective demonstrates that many of the factors that contribute to an individual’s stress are outside of their control and require solutions at the societal level. These factors include poverty, access to medicines and services, and cultural practices, among many.
Yet what emerges is that the patient is simply told to manage their stress, and the societal approach is abandoned. Public health discourse opens on the overarching causes, but on the frontlines, where health is delivered, you are told to make healthier choices.
Poverty is arguably the most notorious of the upstream causes of poor health. An individual who cannot make ends meet is forced to make sacrifices. Do I send my child to school or go see the doctor about my headaches? It may seem like a straight line between poverty and avoidant health-seeking behaviour, but that would be a gross over-simplification.
Why is it that this individual chooses not to seek healthcare? Because they have priorities, and in this scenario, they value their child’s education more than finding out why the headaches persist. But why don’t they have enough financial resources? Perhaps they are self-employed, and business is slow. Why is business slow? Maybe they’re a tourist vendor and the season has not been as booming this year. And the chain continues.
Michael Marmot called these the causes behind the causes. There are even dedicated tools, such as root-cause analysis, that help us trace how one leads to the next.
Ultimately, it is much easier to tell a patient to manage their stress than to ensure a booming tourism season. It is also unlikely that only one individual would be affected by a poor season, and so this single root cause could be responsible for the stress of many Grenadians.
Where public health policy and initiatives are meant to address systemic, upstream and difficult-to-resolve issues, but ultimately ask the individual to manage the consequences of them, is called lifestyle drift.
It is a quiet failure, and an easy one to make. It is easier, and far cheaper, to ask a person to cope than to repair the conditions, such as poverty, that wear them down and cause chronic stress. But easier is not the same as effective. When we ask the individual to absorb a problem that belongs to society, we do not solve it. We simply move it down the chain and onto the shoulders of our most vulnerable.
The truth is that it is a hard pill to swallow. Many of these upstream problems cannot be solved by public health alone. The Ministry of Health cannot single-handedly alleviate poverty. It requires massive collaboration between the Ministry of Finance, the broader government, and society at large. The answers are not easy and require difficult decisions. And yet it must be done.
So, the next time you are given generic advice to manage your stress, it is worth asking the harder questions. The answers to my problems: Are they fully within my control? And what about the causes behind the causes?
Dr Ishma Harford is a medical doctor and a Commonwealth Scholar completing a master’s degree in Health Analysis, Policy and Management. The Health Imperative is an educational, non-partisan column about health, the system that delivers it, and all the implications in between.
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