The father of one of my close friends played a significant role in coming close to wiping out malaria in India in the post-war years. Finally understanding exactly how malaria was transmitted (by female mosquitos, which typically rest on a nearby wall or surface after feeding) made it possible to control the spread of the disease by spraying the walls of houses with insecticide, killing infected mosquitos before they could bite another person. Unfortunately, the best insecticide available was DDT. When its use was reduced due to safety and environmental concerns this, along with other factors, enabled the disease to regain a foothold. Emphasis remains on prevention (by means of mosquito nets, insecticides, insect repellants and draining standing water), rather than cure, since there is no effective vaccine.
I was reminded of this story by the AIDS 2014 conference, which sadly received additional media exposure due to the six researchers who were killed on their way to Melbourne on flight MH17, apparently shot down by pro-Russian rebels. We know the epidemiology of HIV – how it spreads through the population – meaning that prevention as well as cure is possible. In fact, prevention is vastly more effective and desirable than ‘cure’, which really means controlling the disease over the long term using costly antiretroviral drugs. For example, Uganda’s ABC strategy in the 1990s – Abstinence, Be faithful, use Condoms – led to a reduction in HIV infection from 15% to 5% over the decade.
It has been the same with many of the most significant improvements in public health. Ian McColl, former Professor of Surgery at Guy’s and St. Thomas’ hospital in London, noted that ‘the health of a nation is more dependent on public health and social issues than the clinical activities of doctors. The reduction in tuberculosis over [the twentieth] century in this country has much more to do with nutrition and housing than medicines.’1
HIV/AIDS is Africa’s biggest killer. The UK’s biggest killers include heart disease, stroke, cancer, lung disease and liver disease. These are complex conditions, but obesity, poor diet, alcohol abuse, smoking and inactivity constitute a cluster of major risk factors for all of them. They cause 150,000 deaths a year among under-75s. The Department of Health estimates that a fifth of these are entirely avoidable. Instead of prevention, though, we prefer to treat them medically. Statins, a class of drugs which protect against heart attacks and strokes by lowering cholesterol, are now prescribed to around seven million Brits, who take them on a daily basis. In Africa, there is a genuine need for treatment alongside better HIV education. In the UK, we have progressively ‘productised’ health: instead of treating lifestyle and social diseases at their root causes, we can now avoid looking after ourselves for years and then purchase a solution. Ironically, we call this ‘healthcare’, demanding that the NHS pays for more and more.
As in so many other cases, my ostensibly personal decisions affect other people. Motivation for staying healthy is generally considered from the individual’s perspective: my illness is unpleasant for me. However, it also prevents me from engaging fully in the relationships that provide support, belonging and enjoyment, both to me and to those in relationship with me.
We are made in the image of God (Genesis 1:26), an idea which underpins our belief in the dignity of humankind and our equal worth. Universal healthcare is a sound expression of this biblical ideal. But ‘universal’ cuts both ways: my right to receive treatment has to be considered alongside my responsibility to ensure that healthcare remains available for others, by minimising my demands on the service where that’s preventable.
In the Bible, individual responsibility and corporate responsibility go hand-in-hand, both of them parallel outworkings of the requirement to love God and love your neighbour (Matthew 22:34-40).
Regaining our sense of the corporate and of the dignity of humankind will inform our approach to public health, whether that means HIV/AIDS treatment and education in Africa or questions of lifestyle and behaviour back at home.
1Ian McColl, ‘National Priorities for Health’, in Our National Life, ed. Allister Vale (Monarch Books, 1998). See Votewise, p. 72.