Com­bat­ting poverty should be part of any can­cer strat­egy

The Irish Times - Tuesday - Health - - Front Page - Jacky Jones

From the point of view of early di­ag­no­sis, treat­ment, and sup­port for sur­vivors, the new Na­tional Can­cer Strat­egy 2017-2026 is an ex­cel­lent doc­u­ment. How­ever, the preven­tion sec­tion is a big dis­ap­point­ment. Ac­cord­ing to the fore­word by the Min­is­ter for Health, Si­mon Har­ris, “can­cer preven­tion is a cor­ner­stone of this strat­egy as it of­fers the most cost-ef­fec­tive, long-term ap­proach for can­cer con­trol”.

Prof John Kennedy, chair­man of the steer­ing group that put the strat­egy to­gether, also stresses the need for preven­tion and for ag­gres­sive pro­grammes of pub­lic ed­u­ca­tion and “that the most stren­u­ous ef­forts must be made to tar­get more de­prived pop­u­la­tions in can­cer preven­tion”.

Although recog­nis­ing the “in­con­tro­vert­ible ev­i­dence of the enor­mous im­pact of so­cioe­co­nomic sta­tus and de­pri­va­tion on death rates from some can­cers in Ire­land”, he blames smok­ing and poor diet. In fact, the preven­tion chap­ter is all about the pro­mo­tion of healthy lifestyles. This ap­proach will not pre­vent can­cer or re­duce in­equal­i­ties.

Did the mem­bers dis­re­gard the ev­i­dence that inequal­ity and health inequal­ity are the main can­cer risk fac­tors? No, they knew about the health im­pact of inequal­ity. “Re­duc­ing health in­equal­i­ties is a pri­or­ity of this strat­egy, as lifestyle risk fac­tors gen­er­ally fol­low so­cial, de­pri­va­tion, gen­der, and age pat­terns.” The steer­ing group in­cluded a rep­re­sen­ta­tive from the Na­tional Can­cer Registry, which pro­duced a re­port on can­cer in­equal­i­ties last year ti­tled Can­cer In­equal­i­ties in Ire­land by de­pri­va­tion, ur­ban/ru­ral sta­tus and age: A Na­tional Can­cer Registry Re­port 2016.

This re­port showed that not only was there a higher in­ci­dence of can­cer in de­prived pop­u­la­tions, but these pop­u­la­tions had much lower sur­vival rates. “Strong pat­terns of inequal­ity . . . are doc­u­mented for most of the mea­sures ex­am­ined [nine ma­jor can­cer types].” None of the pro­posed preven­tion ac­tions in the new can­cer strat­egy will re­duce inequal­ity and may widen the health gap be­tween so­cioe­co­nomic groups. It is more likely that the steer­ing group recog­nised the im­pact of inequal­ity but did not know what to do about it.

There is over­whelm­ing ev­i­dence that fo­cus­ing on get­ting the lifestyle mes­sage across and on pub­lic health ed­u­ca­tion does not pre­vent can­cer or any other dis­ease. Preven­tion groups know that poor peo­ple get sick more of­ten than those who are bet­ter off, but do not an­a­lyse the prob­lem. They as­sume it is a health ed­u­ca­tion is­sue and be­lieve that if only “the poor” re­alised that smok­ing, drink­ing, and be­ing over­weight was bad for their health they would change their be­hav­iour. Be­cause of this er­ro­neous be­lief, health pro­fes­sion­als, the Depart­ment of Health and the HSE rely on health in­for­ma­tion cam­paigns. They be­lieve that if they say it of­ten enough peo­ple will change.

For ex­am­ple, Goal 1 in the Na­tional Can­cer Strat­egy is di­rected at re­duc­ing the can­cer bur­den by fo­cus­ing on health in­equal­i­ties through in­for­ma­tion cam­paigns. “A sig­nif­i­cant ef­fort is re­quired to en­sure that preven­tion and aware­ness cam­paigns have a par­tic­u­lar fo­cus on ad­dress­ing health in­equal­i­ties” and “it is vi­tal that we are ef­fec­tive in get­ting the mes­sage across to the pop­u­la­tion that each per­son can im­pact sig­nif­i­cantly on their own level of risk of de­vel­op­ing can­cer.” This is so stupid.

Ac­cord­ing to Mar­garet White­head, a World Health Or­gan­i­sa­tion ex­pert on the so­cial de­ter­mi­nants of health and health in­equal­i­ties, “the so­lu­tions may seem so com­plex that peo­ple can eas­ily be­come frozen into in­ac­tion” lead­ing to “lifestyle drift”. In 1988, she wrote The Health Di­vide, which an­a­lysed the huge dif­fer­ences in health be­tween so­cioe­co­nomic groups.

Ac­cord­ing to a 2016 paper by White­head, the rea­son poor peo­ple do not adopt healthy lifestyles is be­cause they do not con­trol their own destiny. “Be­ing in a low so­cial po­si­tion; liv­ing in a dis­ad­van­taged en­vi­ron­ment with a sense of col­lec­tive threat and pow­er­less­ness and the de­gree to which peo­ple are dis­crim­i­nated against and ex­cluded from the so­ci­ety in which they live”, means that peo­ple are more likely to de­velop can­cer and other chronic dis­eases.

Ac­cord­ing to the new can­cer strat­egy, “As more ev­i­dence emerges re­gard­ing the de­vel­op­ment of can­cer . . . there will be a need to iden­tify the most ef­fec­tive preven­tion meth­ods.” We al­ready know the most ef­fec­tive method, which is to re­duce – or, as far as pos­si­ble, elim­i­nate – in­equal­i­ties and thus health in­equal­i­ties. Un­less this hap­pens, the num­bers of peo­ple with can­cer will not just dou­ble by 2040, as pre­dicted in the Na­tional Can­cer Strat­egy, but tre­ble.

Un­less we re­duce inequal­ity, the num­bers of peo­ple with can­cer will not just dou­ble by 2040, as pre­dicted in the ‘Na­tional Can­cer Strat­egy’, but tre­ble

PHO­TO­GRAPH: GARETH CHANEY/COLLINS

The Min­is­ter for Health, Si­mon Har­ris, and Min­is­ter of State for Health Pro­mo­tion, Cather­ine Byrne, at the re­cent launch of the ‘Na­tional Can­cer Strat­egy 2017-2026’.

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