I WAS working as a young doctor for Médecins sans Frontières in Somalia in the late 1990s when I realised for the first time how helpless I was in improving the health of my patients.

I was the only doctor for about 350 000 people. Every day, they’d come through the door, most of them with malaria or another preventable injury or disease, their lives literally in my hands.

As a doctor, I would never have the chance to make such a difference clinically as I did during those months. But I felt like I was just standing on the banks of a river, repeatedly diving in to pull people out, saving a life only to watch the next person slip into the water. Once I’d returned home from Somalia, I realised, nothing really would have changed.

What could be done, I wondered, to stop people falling into the river in the first place?

I believe this is the fundamental problem facing health in high income countries. We’ve become so focused on treating disease that we’ve forgotten to look at what’s causing people to fall ill in the first place – the factors at the source of the river that determine whether or not people enjoy good health.

The United States spends more on health care than any country in the world – about US$3.5 trillion in 2017 – but is seeing diminishing returns. US life expectancy has been falling in recent years as more young people die from drug overdoses, suicide and liver disease. It’s a trend mirrored in the UK, with slowdowns in life expectancy occurring throughout Europe too.

The more we spend, the sicker people become. We are conflating the concept of health with the practice of medicine. The modern health system is actually an illness system. We are not investing in health, we are investing in health care.

Australia’s health is among the best in the world, but this comes at a cost. Health spending is at an all-time high – more than $181 billion a year – but it’s not clear what bang you’re getting for your health care buck.

More than half of Australians are living with a chronic disease – a lifelong condition such as heart disease, asthma, cancer or diabetes that causes significant disability and reduced quality of life. Nearly one in four Australians is estimated to have two or more of these conditions.

The health system is beset by serious inequalities. Aboriginal and Torres Strait Islander people, those from low socio-economic backgrounds, people living in rural and remote areas and people with disability experience significantly worse health than other Australians, including more illnesses and a shorter life expectancy.

What is the government’s response? Like jurisdictions worldwide, it’s reacting to worsening health by doubling down on medical solutions. Millions of dollars are ploughed into pharmaceuticals, targeted medicine and new technology, but where’s the investment in prevention?

When it comes to preventing disease, we still frame the problem as one of personal responsibility. There’s been an explosion of wellness blogs, diet advice, tips on how to walk 10 000 steps, but none of it is working. In both the US and Australia, people are getting fatter, more inactive and more at risk of chronic disease.

It’s useless giving people lifestyle advice without addressing the more deeply rooted problems that cause ill health: poverty, lack of education, unavailability of healthy food or safe spaces to exercise, climate change. These are the drivers of ill health, and we ignore them at our peril.

New Zealand recently launched a Wellbeing Budget, which aligns budgetary policies with key priority areas such as improving mental health, reducing child poverty, addressing inequalities faced by Indigenous people, thriving in a digital age and transitioning to a low emission, sustainable economy.

The New Zealand model frames disease prevention in terms of return on investment. Expenditure is justified by long term improved health outcomes and social and economic returns.

Australia would do well to consider a similar framing of health problems such as chronic disease, mental illness and drug use. None of these can be successfully managed without addressing the injustice, racism and hate at their source. No matter how great our hospitals or advanced our technology, health is limited by the world in which people live.

The first step is to change the way we talk about health, at a grassroots as well as at a policy level. Seeing health for what it is, a result of factors embedded in everyday life, is just as important as investing a new hospital or magnetic resonance imaging machine.

Dr Sandro Galea is a physician, epidemiologist and author, and Dean at Boston University School of Public Health. He is visiting Sydney and Melbourne as a guest of the The Australian Prevention Partnership Centre.


The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.


We should shift our emphasis from curing illness to preventing illness
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7 thoughts on “Time to invest in health, not just health care

  1. Jessica Behrman says:

    Other factors working against many people are so ii-economic. I can’t speak for Australia but in the US, the less income you have, the harder it is to stay healthy and fit even with a strong desire and good intent.

    Less time to prepare healthy food at home, to purchase organic as much as possible, to exercise, the addictive design of processed foods (sugar, salt and fat, additives), retained toxicants – together, these can be insurmountable for many people.

  2. Anonymous says:

    Beautifully written article.Just announced we are spending even more money on the PBS subsidising a few very expensive drugs that will benefit a small number of people live a little longer rather than looking at prevention.The money is there but needs to be used more sensibly

  3. Anonymous says:

    A lot of the issues the good doctor raises are individual moral issues. A sedentary lifestyle, crappy eating habits, drug taking. A quick look around at a shopping centre, taking note of the number of fat, overweight, obese people, many of them quite young, and you see the extent of the problem. Wellness starts with respecting oneself. Govt programs aimed at getting people to be more active, playing sport and generally living a healthier lifestyle are to be welcomed. Neglecting one’s heath is immoral and the health debate should be framed as such.

  4. Urban Sundvall says:

    Hej anonymous comment 3.
    As a therapist who believes in calling a spade a spade, in an appropriate way, I think you may indeed have more effective results in avoiding the insulting language. If I had chosen to call you “ an insensitive arrogant bugger” I’m sure that you probably wouldn’t appreciate it any more than the people you wanted to comment ” get off your bum you fat bugger and stop smoking” to.

    Most people in the situations of wanting to get slim and healthy actually need real help not insults.
    They are often where they are in life because they have not yet had the ability learn better strategies in dealing with life’s ups and downs.
    They need our help, not abuse. No matter how altruistically it’s meant to be. Perhaps you too could do with a few strategies so you do not feel the need to hide behind “anonymous”.
    There are many of us who work in the field of Mind Work who would love to be of help to anyone needing help.
    The next time you have someone who needs help, please refer them on to a practitioner who can do so if you do not yet have either the skills or the time to do so?.

  5. Anonymous says:

    How do the anti discrimination policies affect chronic health with respect to weight, diet, smoking. why can’t we truthfully and with true concern say to someone _” get off your bum you fat bugger and stop smoking” rather than being politically correct. We are no longer allowed to UPSET the patient or our colleagues in the workplace when our intentions may be altruistic. I am always told I can’t say that – but I respond with ” but why not everybody is thinking it?” I hear the argument these comments don’t help anyone and simply make them more depressed and apathetic. The softly, softly approach ain’t working – try the alternative.

  6. Urban Sundvall says:

    Bravo Dr Sandro Galea!
    It is true!
    We, here in Australia, are fortunate to live in a country with so many so many fantastic opportunities available. And yet… there are so many who are either denied or simply not offered those opportunities when it comes to health. Often due to inabilities to access them due to restricted finances, both personal and governmental.
    The Return On Investment from the financial focus on building health instead of battling illness will be enormous when it takes effect.

  7. Anonymous says:

    A succinct, eloquent piece. It summarizes nicely the most critical issue in our country’s health and health care.
    The most recent edition of the Public Health Research & Practice journal refers to the ‘Commercial Determinants of Health’ – those drivers that promote the sale of unhealthy products and activities, and which feed that fast-flowing river to which the author alludes.
    There is also of course the paltry percentage of the health budget those goes towards meaningful prevention, said to be $89 per person, or 1.3% of all health spending (Jackson and Shiell, 2017) – and even that is not reaching those with most need – the ‘inverse care law’ strikes again.

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