Professor Field, outgoing chair of the college I spend a small fortune to be a member of, the Royal College of GPs, has been on the radio rather a lot today. The news is: he scribed a cross article for the Observer, saying that
“…too many of us neglect our health and this is leading to increasing levels of illness and early death….I believe that parents who smoke in cars carrying small children are committing a form of child abuse; I suppose the same people also smoke at home in front of their children. ……Parents really do need to take more responsibility, but this should start even before conception. Many of these avoidable deaths can be linked to low birth weight as a result of mothers smoking while pregnant. Cot death, or Sudden Infant Death Syndrome, is also directly related to smoking. …..Obesity in pregnancy is also increasing and this is a very worrying trend. Parents need to act as role models from early on and take control of their children’s eating habits by providing sensible, appropriate portion sizes and by not feeding them rubbish..”
If you want to read the whole thing, it’s here. The crux is that doctors are to tell patients to take responsibility for their lifestyle, and thus, health. Didn’t we know that already? The thing is, I quite like the idea that doctors are not moral guardians, and are not in existance to hector, cajole and blame patients for everything that they ‘admit’ to and has a tick on the ‘risk’ list. Professor Field seems to think that GPs are to lead the way with telling people how to live their lives. His article does not even begin to address the question: why? The real issue is that in this first world country, where life expectancy is generally increasing, the divide between health between rich and poor – and corresponding mortality rates – is widening.
I don’t believe that people don’t know what’s best for them. Smokers feel guilty if their kids are about when their cigarettes are lit. Overweight people often feel unattractive and tired. But cheap food tends to be fattier and more calorific, and if you live in a high rise, with no local hub or infrastructure, and where the green patch has a big sign saying ‘no ball games here’ it may become a little clearer why social inequality exists. If your corner shop stocks cheap drink and no fruit – well – some choices are easier to make than others.
The comments Field makes about melanoma are also wide of the mark: the relationship between melanoma, the most dangerous form of skin cancer, are disputed. See here. And in any case, there is also valid concern that kids are not getting enough vitamin D, which requires UV. What of the claims that cot death is associated with smoking? True, there is an association – which is not necessarily causation. But delivering the information he does in the manner he does I fear will make families who have been through the horrors of cot death feel pretty bad. And non smoking families have cot deaths too.
I don’t want my patients to come to me dreading a lecture on smoking and weight first. I also don’t want to put off an overweight or smoking person seeking advice about serious symptoms for fear of being told what they are doing wrong (as if they didn’t know.) If the RCGP wanted to do something useful to reduce health inequalities they would be campaiging for decent living pensions for a start – the theory I have often heard is this – who wants to live to 75 in miserable poverty when you can lop a few years off and enjoy your alcohol and cigarettes along the way?
Is there even any evidence that doctors – or anyone else for that matter – hectoring people to change their lifestyle does any good? There is some evidence that doctors offering stop smoking advice to specific patients in a non judgemental manner increases quit rates very slightly. But that’s it.
The paternalism of medicine was meant to have died off a few years ago. The radio today had an annoying refrain that Field speaks for the 40,000 or so GPs in the UK. Not I. Is there even a doctor who is a perfect weight, exercises regularly, never eats unhealthy food or drinks to excess, does not smoke, has never tried drugs and has never had risky sex? It would be far more useful if doctors wishing to engage with public health focused on asking ‘why’ is is that people make the choices they do.