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Terry Maguire is a community pharmacist in Belfast
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The early months of the year are a depressing time. Traditionally it
is the time when New Year resolutions are finally assigned to the bin,
when you find your alcohol intake back to pre-Christmas levels, when
you bitterly regret taking out that three-month gym offer and think up
ways to get your money back, and when your calorie intake (which you
blame on a genetic predisposition to seasonal affective disorder) is
sufficient to double your body mass index by Easter if you do not get
it under check.
We are so bad at being good, the Health Police constantly tell us. So
it is a relief when Vested Commercial Interests tell us to relax, take
it easy and indulge ourselves “because we’re worth it”.
John Reid’s White Paper “Choosing health” and his more
recent paper “Choosing self care” — both strong on
the principle of choice — attempt to accommodate this conflict
and try to marry the extremes of hedonism and asceticism in the creation
of a consensus policy on public health that, it is hoped, most of us
can live with. Mr Reid knows that, like himself, we are only human and
surely there are worse things in life than being overweight, inactive
or a lecherous, drug-taking drunk. Everything in moderation; life should
be about balance. We just need to make the right choices.
Of course, it is not that simple. We consistently fall short of achieving
the necessary balances that assure good health for everyone. Government
policies and resultant regulation have been, in relative terms, spectacularly
successful in achieving the necessary environment that nurtures a “reasonably” healthy
population. Yet in some areas, for example where policies attempt to
address complex systems and the problems addressed are not based on simple
cause and effect models, strategies often result in undesirable and unexpected
outcomes.
The obesity epidemic is a good example of this. We are fatter than ever
because of a range of diverse well-intentioned government policies across
a wide range of government departments going back over 30 years. Obesity
is not a disease or an abnormality it is a normal response to an abnormal
environment: an environment where high calorie, highly palatable food
is available all day, every day, with no need to expend energy seeking
it out. Telling people to eat less and take more exercise seems relatively
ineffective in addressing the progress of this epidemic.
On radio just after Christmas, I was scathingly critical of a local video
store and was in turn accused of being patronising and interfering. My
angst came not from the fact that they loan videos and DVDs — I
use this service myself — nor was it due to the fact that they
had introduced (and were advertising widely) a popular ice-cream franchise.
My ire stemmed from their introduction in each store of a kiosk selling “diet
pills”.
Of course, this is perfectly ridiculous from a public health point of
view but it makes total sense from a business point of view. I was being
a hypocrite, I thought. I, too, sell these same over-the-counter “diet
pills” in my pharmacies. So can pharmacy add something to these
sales and avoid the accusation of profiteering on an unrealistic expectation — the
need to remain as thin as the heroes in the videos?
If “diet pills” can give people an initial motivation to
change (all that can be expected from anti-obesity medication) and the “diet
pills” are supplied along with objective advice and support then,
I like to think, pharmacy can add value. In conjunction with a local
women’s community group, our pharmacies developed (and continue
to provide) a service to address obesity, namely, the “healthy
weight challenge”.
Our service is strong on personal responsibility and does not offer easy
fixes; people entering the programme are encouraged to consider their
role and responsibility in managing their own weight before targets are
set. The programme is based on a successful smoking cessation service,
the “smoking challenge”, that we developed previously. Our
approach then was that we can never stop anyone smoking or achieving
a healthy weight; people can only do that for themselves. All we can
do is educate, motivate and support the process. We waste time attempting
to force change where it is unwelcome. No patient is the same, so flexible
strategies are needed.
Take Sidney, a 36-year-old man with learning difficulties who is living
in care and is grossly overweight. Sidney’s current BMI is 40.
Care staff would like it down to 30 by the summer. Sidney’s GP,
shocked by his out-of-control waistline, has all but accused care staff
of attempting to kill him! Such blame is gratuitous; his carers do an
incredible job. Sadly, policies stop care staff denying Sidney his human
rights so he is fed handsomely three times daily and no one interferes
with his right to snack between meals on crisps and soft drinks. Policy
also recommends that Sidney should not walk to work unaccompanied so
a bus is provided to bring him to and from his home and the day centre — a
distance of about one mile and easily walked. Granted, Sidney has been
abused by local youths so he is reluctant to venture too far from his
home.
Our suggested solution — less calorie intake and more activity — involved
negotiation with a number of agencies, including his GP because Sidney’s
anti-psychotic drugs have contributed to his weight gain. Sidney himself,
now that an interest has been taken in him, is keen to see a positive
outcome and has achieved a modest weight loss in the past few weeks without
support from any “diet pills”.
As pharmacy seeks to develop a public health role we need to resist the
temptation to design services based on simple cause and effect models.
Public health is steeped in complexity so service design must address
complexity. In this way sustainable solutions can be found to what appear
to be intractable public health problems.
We all know that classic chaos theory suggests that a butterfly, by beating
its wings somewhere in the southern hemisphere, can cause hurricanes
in the northern hemisphere. Small inputs, in specific conditions, bring
massive, disproportionate outcomes. Public health is a complex system
since it involves human beings who are, on the whole, irrational and
whose behaviour cannot easily be explained by simple cause and effect
modelling.
Pharmacy makes, and will continue to make, an important contribution
to improving public health but we need much more innovation in how we
do this. “Building the community pharmacy partnership” in
Northern Ireland is one such approach that allows for this flexibility
in service delivery. Commissioners of public health services find such
service models challenging because they prove difficult to monitor. Many
pharmacists find this way of working uncomfortable but this can be addressed
with thorough training to develop the necessary skills, such as motivational
interviewing (PJ, 13 December 2003, p813 PDF (120K)).
I am not convinced that the choice Mr Reid is seeking will do much for
the health of the public, except perhaps for the horsey, head-scarf wearing,
green wellington brigade, who, perhaps, do not need any help. There is,
and I feel sad conceding this, a need for urgent and strong regulation
of certain parts of the food industry which, frankly, has a blatant and
cynical disregard for public health. For people like Sidney, choice means
something very different to what John Reid would like to think it means. |
The
Pharmaceutical Journal