Prof. Henry Becker on the critical changes needed to avert the national health crisis
Like most Western countries, and increasingly the rest of the world, Canada faces a staggering, swelling burden of medical costs that challenge its ability to maintain the quality, comprehensiveness and universality of health care services. In April 1991, the federal government set up a Commission on the Future of Health Care in Canada, headed by Roy J. Romanow. Its mandate was to review medicare, engage Canadians in a national dialogue on its future, and deliver recommendations for enhancing the system's quality and sustainability. The Final Report of the Commission, Building on Values: The Future of Health Care in Canada, was published in November 2002 (http://www.hc-sc.gc.ca/english/care/romanow/). Unfortunately this otherwise laudable, public-spirited and thorough study falls far short of its stated goals.
Not one title among the 40 discussion papers commissioned from scholars, policy analysts and experts across Canada and internationally mentions prevention.
Although Romanow acknowledges in his preface to the report that, "it is common sense for our health care system to place a greater emphasis on preventing disease and on promoting healthy lifestyles", only 7 out of 354 pages deal with prevention, and the greater part of that on the evils of tobacco and on vaccinations.
The report presents 47 recommendations, of which only three relate to prevention—one on reducing tobacco use and obesity, another on promoting physical activity, and the third on a national immunisation strategy. This projects and encourages, in my view, a most unfortunate skewing of priorities that is not in the public interest.
The Canadian situation has much broader relevance, as the diseases of industrial civilisation have taken hold and health care systems are bending under the load nearly everywhere. Significantly, a United Nations study in 1999 found the prevalence of overweight and obesity—a strong predictor of chronic ill health and shortened lifespan—to be increasing alarmingly in the developing countries as well as the developed, and particularly among children. A worldwide epidemic of obesity has been recognized, spread by globalisation and penetrating to the remotest corners of the world.
During the past century, the common afflictions in Western societies have dramatically shifted from infectious to degenerative diseases. Infectious diseases were subdued largely by public health measures: improvement in housing, provision of clean water and air, sanitary waste disposal, quarantine of the infected, etc. Rise in living standards and education also helped. Medical interventions such as vaccinations and increasingly potent drugs came relatively late, but in today's public imagination, they get the major credit for ridding us of infectious diseases.
Infectious diseases typically strike in unpredictable waves, or epidemics. Degenerative diseases, however, have typically risen from small beginnings and grown nearly exponentially to a level where much of the population is chronically afflicted. Today these diseases are the major burden on our health care system, and their proliferation the main cause of spiralling costs.
While some degenerative diseases have occurred in various societies throughout history, those which most vex us now, such as cardiovascular disease, inflammatory bowel disease, type II diabetes, asthma and many cancers, were rare or virtually unknown a mere 80 years ago. Cases of myocardial infarction (heart attack), for instance, began to appear in the 1920s and grew decade by decade to epidemic proportions. Most degenerative diseases are not caused by disease vectors such as micro-organisms or viruses. They are primarily due to 'lifestyle' factors of both the individual and various layers of society and, as such, are highly preventable. These factors include faulty food, dietary immoderation, abuse of harmful substances, physical inactivity, disturbed biorhythms, environmental deterioration, social breakdown and poverty.
The most important determinant of health is food. Just as good nutrition is vital for a healthy immune system, faulty food is implicated in the infectious diseases. In his book The Wheel of Life, first published in 1938, G. T. Wrench observed, "The inescapable conclusion is that in a very large number of diseases faulty food is the primary cause. The suspicion is that faulty food is the primary cause of such an overwhelming mass of disease that it may prove to be simply the primary cause of disease [in general]."
Hippocrates taught, "Let thy food be thy medicine". The corollary we must learn is, "Let not thy food be thy sickener!"
It's important to realise there were once whole populations—not just individuals here and there—flourishing in states of robust good health and virtual absence of disease. That is not a utopian myth, but well-established fact. The evidence is compelling that our hunter-gatherer paleolithic ancestors who subsisted mainly on animals supplemented with such wild plant foods as were available—tender leaves and stems, roots, fruits and nuts, but virtually no grains—typically had fine physiques and enjoyed remarkable freedom from degenerative disorders. Sea foods appeared to be particularly valuable, and there is a growing school that argues these were pivotal in the special development of the human brain.
Since the Neolithic (agricultural) revolution 10 000 years ago, many agricultural communities that maintained a sufficient animal component (fish, meat, milk, cheese) in their diets also achieved excellent health. Examples of healthy communities have extended into our own time, though in rapidly diminishing numbers. They have been scientifically observed and documented, most notably by Weston A. Price (Nutrition and Physical Degeneration, first published in 1939), Sir Robert McCarrison (Studies in Deficiency Diseases, 1921; Nutrition and national health, in J. Royal Soc. of Arts, 1936), and Viljhalmur Stefansson (The Fat of the Land, 1956; Food and food habits in Alaska and Northern Canada, in Human Nutrition, Historic and Scientific, 1958)
These lessons of the past demonstrate what's possible for human health, and what can be achieved again. The foods eaten by healthy peoples of the past were perforce "organic", as no others existed before modern industrialised agriculture. They were whole, fresh and completely natural. The genius of industrial civilisation has been to introduce a vast array of highly processed foodstuffs that are anything but whole, fresh or natural. Attention is paid to packaging, appearance, presentation, palatability, uniformity, convenience, transportability, shelf life and—it must be said—addictiveness, while almost wholly ignoring the crucial issues of nutritional value. A gigantic middleman—the processed food industry— now stands between the consumer and the primary producer (the farmers, ranchers, fishers, etc.) and profits richly from economic value added. The consumer buys these products, which are typically heavily promoted, and pays the predictable price of nutritional value subtracted, i.e., degenerative diseases.
The growth of degenerative disease is an indubitable economic burden on society as a whole, but enterprising parties have skilfully exploited that as an opportunity for profit. This gave birth to the pharmaceutical industry, another mega enterprise of our times. The main effect of the industrialisation of medicine on degenerative diseases is palliative rather than curative, usually with many adverse side effects. As with processed foods, the manufacturers' interest is overwhelmingly the pursuit of profit.
Finally, the "health care" system has come to rest on acceptance of degenerative diseases as inevitable features of life and the medical treatment of symptoms as the normal response to this grim reality. There is, to be sure, an ongoing quest for "cures", e.g., the "war on cancer", but what it mostly accomplishes is to produce ever more drugs that fall well short of the ever-receding goal of cure but succeed at return on investment.
Physicians are indoctrinated in and co-opted into this defeatist paradigm by their basic training, and reinforced by their continuing education at the hands of the pharmaceutical companies. Thus, the people we should expect to tackle the plague of degenerative disease at its sources, instead act like firemen who have strategically decided not much can be done to stop fires from happening, so it's best to downplay prevention and concentrate on fire-fighting.
So how did we get here? These are some in the long list of our 'lifestyle' failings:
I shall limit myself here to addressing nutrition, the single biggest determinant of health.
A paradigm change is needed in medicine
"Orthodox" physicians have too long based their practice principally on knowing drugs. To prevent or effectively treat the degenerative diseases, they must know food and make it their primary instrument. These diseases are largely caused by faulty food, and cures—to the extent possible—depend largely on the prescription of the right food. The education of physicians has too long neglected nutrition. Physicians should, in fact, be thoroughly acquainted with all the lifestyle factors that promote health or precipitate disease. Although still a minority, a growing number of physicians are already committed to prevention and cure by lifestyle modification. Currently, their practice is commonly referred to as "alternative", but it is time for them to become the main stream.
Major changes needed in the field of applied nutrition and nutritional goals
There are many things very wrong today in applied nutrition and the nutritional goals set for citizens by authorities such as Health Canada. Standards such as Canada's Food Rules and the USDA. Food Pyramid are badly skewed and need drastic revision. The obsession with the alleged dangers of dietary saturated fats and cholesterol is a proven but persistent and egregious folly. There's nothing wrong with sound natural fats. Nor is there anything wrong with beef and lamb, with all their fat, if the animals are healthily raised and not dosed with antibiotics and hormones. There are, though, truly bad fats that indeed do contribute to degenerative diseases: synthetic fats; partially hydrogenated fats; oxidised and rancid fats; and excesses of omega-6 fatty acids. Carbohydrates have been hugely over-promoted; the healthiest amount of sugar is none, and white flour products aren't much better. Processed foods should be revealed for what they are: mainly junk, dangerous to health, and never a fit substitute for whole, natural foods. Synthetic foods, such as soft drinks, are typically slow poison. I can hardly begin to list all the reforms desirable in nutritional teaching and consultation. It is essential to get the story right according the best knowledge of the facts, and to stay open to correction by new findings. It is also necessary to get the story out so the public is well informed, without kow-towing to industrial interests (processed foods, agrobusiness).
Optimum nutrition must be our aim
Optimum nutrition is especially crucial for good outcomes during conception, pregnancy, infancy and childhood, the whole process in which new humans are moulded for better or worse. Canada should be vigorous in providing parents with supportive information, programmes, resources and assistance. Lifelong good nutrition is the foundation of a healthy and happy old age. But even when many years have been lived in poor nutrition, appropriate changes in diet can still ameliorate much of the damage done and greatly diminish needs for medical treatment. The nutritional quality and adequacy of food served in homes for the aged should be a matter for public concern and government attention.
Optimum nutrition is not uniquely defined, diversity and individuality must be respected
Canada has citizens with ancestry in all regions of the world: central African and south Asian, Mediterranean, North European, and from recent hunter-gatherer to 10 000-year experience of agriculture. Thus there is a broad range of food tolerances and intolerances that should be taken into account rather than prescribing a one-size-fits-all. The case of Canada's first nations is especially notable for suffering from the foods of industrial civilisation in high rates of type II diabetes, cardiovascular disease, etc. Generally, everyone is an individual with characteristics that may deviate substantially from the average and merit special attention. One of the jobs of the enlightened physician will be to discover those individual vulnerabilities and needs and help the patient make due adjustments.
Public institutions must set an example
Publicly funded hospitals and institutions of education, and cafeterias and restaurants in government buildings, should lead by behaving as models of excellence in the foods offered on their premises. Currently, a minority of schools, colleges and universities offer their students healthy food and drink. Many, however, have admitted fast food outlets to their halls, with monetary benefit to the institution but a great disbenefit for the health and food habits of students and staff. Utterly scandalous are the deals with cola companies.
Huge reforms needed in agriculture and animal husbandry
A return to wholly organic operation is needed to put an end to the incidental poisoning of land, water, air, people and most other life forms. Today's high-input "modern" agriculture is simply mining the land, sapping future productivity for the sake of temporary monetary gain. It's not sustainable. Further, the concentration of animal production on factory farms should be stopped and production redispersed over the land. Animals should be raised humanely and in such a way that they are naturally healthy. Grazing animals should be raised largely by grazing; it is part of what gives their meat and milk high quality. Much greater attention should be paid to raising the nutritional quality of farm, ranch and market garden products.
Government must ensure quality in food supply
Government should not hesitate to use its powers of regulation, inspection and stimulation to ensure high quality in the food supply. Programs to recognise and promote quality, such as is happening with Canadian wines and Québec cheeses, should be expanded to other products. Quality production should be encouraged. The nutritional implications of any food processing should be evaluated by competent agencies and adjustments required to ensure acceptable nutritional outcomes.
National and provincial laboratories need to be reinvigorated
They should be given a new mandate and funding to effectively serve the public interest with appropriate research in nutrition, testing of foods and drugs, etc. Their primary concern should be protecting and informing the public, rather than assisting industry and promoting business. The government should also fund a number of university research Chairs and/or Institutes specifically to work on questions of food and nutrition that are of significant national or local importance.
In order to deliver health, we must deliver good food through implementing sweeping changes in medical education and goals, food and agriculture and government policies. We may still need as many physicians, if they indeed become guardians of our health rather than managers of disease. Economies will result primarily from vastly reduced demands for diagnostics, hospital care and other patient services, and medical therapies (medications, radiotherapy, etc.). Sales of pharmaceuticals may plummet, but the sacrifice of this economic activity will be happily endured as part of the price of better health. The same may be said of major sectors of the processed food industry.
The many people who regard degenerative disease as an inevitable feature of living are wrong. We've seen these diseases proliferating and appearing earlier and earlier in life, so young children are now succumbing to obesity, Type II diabetes and even cardiovascular disease. However, if the needed reforms are made, onset of such diseases can be retarded and relegated to extreme old age, and indeed most of these diseases need not be commonly experienced at all. The choice is ours.
The author is Professor Emeritus of Chemical Engineering, Queen's University, Kingston, Canada. This paper is based on his submission to the Romanow Commission and a forthcoming book.
Article first published 15/07/04
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