versão On-line ISSN 2078-5135
versão impressa ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.103 no.4 Cape Town Abr. 2013
Doctors' lifestyles vital for SA's health -global expert
Overweight, smoking doctors 'make terrible counselors', says Dr Derek Yach, the South African former tobacco-control activist who rose to lead the World Health Organization (WHO)'s Framework Convention on Tobacco Control and its strategy on diet and physical activity.
He says research shows that doctors who smoke and present as overweight or obese are 'far less likely' to counsel their patients or become effective disease prevention agents, let alone engage in any public discourse on legislative health measures.
Speaking at a Discovery Vitality Institute media breakfast at Cape Town's Waterfront in February, Yach said that changing behaviour will require changing individual perception, not coercion - and the most powerful weapon will be an open-ended democratic discourse in the media. He argued that the more the discourse appears to be 'polarising', the more behaviour actually changes, and said that with so much of the world's disease burden being preventable, a vital question to ask is, 'Why don't we do it [promote behaviour change]?'
'Today's pleasures v. tomorrow's rewards'
Yach is the new head of the US Vitality Institute (now partnered with the USA's
Humana group). He said that when it comes to tobacco and nutritional choices, the problem is that people 'favour today's pleasures over tomorrow's rewards'. Societal pressures and environmental factors make health choices tough.
'As physicians we carry an ethical responsibility to cure the sick, often at the expense of prevention,' he said. 'Often we fail our patients when faced with prevention opportunities ... we have yet to adapt our thinking and some successful approaches to tackling acute episodic risks - and those "controllable" through simple interventions - to chronic disease risks.' There is also a 'strong pull' to avoid resolving competing interests across sectors, while an 'accounting' system values today's consumption over tomorrow's sustainability, and invests in treatment over prevention.
On the subject of smoking and overweight physicians, Yach joked that press photographers would have had a field day at the recent 6th World Congress of Paediatric Cardiology and Cardiac Surgery in Cape Town (where he presented a paper) in February. At every break in proceedings, the forecourt and open spaces at the International Convention Centre were packed with cardiologists puffing away. 'I'd have no qualms about taking pictures of them, but perhaps not of Members of Parliament (MPs) because that could send the cycle the other way,' he opined.
Change your MP's lifestyles and change society
He challenged health journalists at the breakfast to start a media competition challenging MPs to adopt healthy lifestyles, as a way of sparking a public discourse, adding that unless decision makers are motivated to bring about change, 'nothing will happen'. As the former executive director of WHO and former senior vice-president of global health and agriculture policy at Pepsico, Yach said he'd learnt to live with 'constructive ambiguity' over the years. (He also headed Global Health at the Rockefeller Foundation.)
'Working at Pepsico was not easy but I had a CEO totally committed to change in spite of market forces,' he said, adding that big corporates with negative public health profiles need to change their revenue bases to achieve any kind of long-term success.
Yach praised recent wellness initiatives by national health minister Dr Aaron Motsoaledi and Western Cape Premier Helen Zille, but proposed some tweaks to their strategies. The minister has declared war on the tobacco, alcohol and fast-food industries,™ and Yach suggested that Motsoaledi, 'perhaps needs to tailor his approach to each sector, taking into account their sensibilities and profiles and he may get further'. In his annual 2011 budget speech, Motsoaledi also defined the existing healthcare system as 'lopsidedly curative, hospi-centric, destructively costly and unsustainable'.
Yach said Zille's application of the latest behavioural economics theories to create incentivised HIV testing and regular drug testing in her province (which unleashed a storm of protest over 'stigmatisation and inequity')™ was based on 'a deeper understanding of what truly motivates change below the surface'.
'Most government-led programmes assume that people will make the rational choice based on the data and evidence, but the reality is that people make choices based on their best interests in the short term. What's needed is what is now being called "nudging".' The 'downside' of this is the necessity of avoiding discrimination by ensuring that all those who could potentially be on the programme have the choice to 'opt in or opt out,' while still getting the benefit of the preventative measure. The problems of confidentiality and voluntary participation were 'important, but by no means insurmountable,' Yach said. The World Bank and many global development agencies constantly used poverty alleviation and development economics to develop better social policies. This has prompted Discovery Health to recruit the globe's top experts to try and incentivise behavior.
'I don't think Helen [Zille] got anything fundamentally wrong. Perhaps the way she presented it without being explicit about discrimination or addressing sustainability
- always an issue with financial incentives
- got in the way,' he said. He speculated that her critics did not fully understand the latest, widely embraced literature on the subject and suggested Zille fly out some of the world's top authors, such as Daniel Ariely,[3-'to help demystify things'.
Asked to single out one nutritional measure that would have a lasting impact on South Africa's disease burden, Yach cited the globally proven linking of schools in rural areas to local fruit- and vegetable-producing farms, with their urban counterparts linked to healthy food outlets. 'The rubbish they sell in tuck shops is hard to believe,' he added.
Yach, who still advises Pepsico, established the Centre for Epidemiological Research at the
South African Medical Research Council and has authored or co-authored over 200 articles covering the breadth of global health. He serves on several advisory boards, including those of the Clinton Global Initiative, the World Economic Forum, the National Institutes of Health's Fogarty International Center and the World Food Program USA.
1. Bateman C. Motsoaledi declares war on disease-causing products. S Afr Med J 2011;101(8):503-504. [ Links ]
2. Bateman C. Critics 'chew' furiously on Zille's HIV/drug-testing carrots. S Afr Med J 2012;102 (1):12-13. [ Links ]
3. Ariely D. Predictably Irrational: The Hidden Forces that Shape our Choices. London: HarperCollins, 2008. [ Links ]