Translator: Sebastián Rojas Reviewer: Sebastian Betti
When I chose to study medicine, I did it convinced that by doing it
I could help to improve the health of people.
With time, I've realized that improving health is an everybody's thing
and not just something of us, doctors.
The first one who opened my eyes was my preventive medicine professor
with a very simple graph: "Evolution of the Mortality Rate by Tuberculosis."
The mortality rate by tuberculosis decreases continuously and slowly
from over 4000, to less than 10 deaths per million inhabitants
in a country like England.
As the rest of the class, I knew that by the end of the 19th century
how the disease is transmitted was discovered.
By 1950, the first antibiotic, and soon after, the first vaccine.
What we couldn't imagine, what surprised us all,
was seeing how this mortality rate had already started to decrease
long before the bacteria was discovered.
And that the discovery of the antibiotic and the vaccine barely modified
the decrease rate.
But so, what caused such a decrease
in the mortality by tuberculosis?
There were mainly two things:
the sanitation of cities and homes,
and the improvement of nutrition.
There I started to realize what I've come to explain to you.
If we want to improve our health, if we want to progress in health issues,
we have to look beyond health services.
We have to change our focus and we have to, first, invest in
what is really affecting our health, and second, take action on a level
that includes the entire population, not just a few.
Let's consider the first idea: What's affecting our health?
What defines it, what is known as "health determinants,"
we can split it in four groups.
The first of them is life conditions.
The neighborhood we live in, our working conditions,
the education our children get, nutrition, exercise,
whether we smoke or not...
I'm going to give you two examples based on real data.
A city, Barcelona, and its difference between life expectancy
between its poorest and its richest neighborhood.
Ten years. A difference of life expectancy of ten years
in a single Spanish city.
Another example: Andalusia; people without education
or just with basic education have a health twice as bad
as those with higher education.
It is estimated that life conditions
determine almost half of our health.
The second group of health determinants is our environment.
It is estimated that it determines around 20 percent; without a doubt,
the most important one, is atmospheric pollution, that each year, globally,
it kills 3.7 million people.
In a city like Seville, if its air pollution levels were reduced to those
of London, 300 early deaths would be prevented.
The third block of health determinants is our biology,
which is estimated to determine around a fourth part of our health.
Our complexion, our genetics, as you know, there are certain diseases
that have a genetic base.
And ultimately, health services,
which are estimated to determine 11 percent of our health.
The quality of the health service, the proximity of health services
the kind of health service.
In Spain we are very lucky because we have a high quality
health service, and most importantly, of universal and free access which allows
everyone to access it
irregardlessly of our pocket.
Irregardlessly of our economic condition.
As you can see, our health depends on health services,
of course, but is also depends on our life conditions and our environment,
that together determine over 60 percent of our health.
Let's now see, of that invested by a country on health,
what part of it is invested on each one of these health determining groups.
How much do you think they invest in our life conditions
and in our environment?
3 percent.
And on health services?
90 percent.
Currently, we are investing a lot of money on health services,
which is good, it's necessary, but the problem is
we're investing very little on that which determines
over 60 percent of our health.
Yet, we have some good examples of health investment
beyond health services.
By the end of the 60's, some studies were published that concluded that
lead had serious effects on human health,
particularly, on the neurological development of children.
Scientists were able to convince governments, and they started
a series of actions to reduce lead levels in gasoline, among others.
The reduction of lead in gasoline
led to the reduction of lead in the atmosphere.
Thanks to this intervention, the IQ of children
increased, no more and no less, than four points.
Countries that did it improved the health of their children a lot.
Moreover: it's been estimated that the economic benefit of these policies
is over, pay attention, $300 billion a year
only considering productivity.
But we still have a lot to do.
An area in which we can do a lot for our health
is atmospheric pollution.
As I was saying, in a city like Seville, 300 deaths per year could be prevented
if its pollution levels were reduced
to those as the ones of a city like London.
And I mention London because among all big European cities,
it is the one with the pollution levels
closest to those recommended by the World Health Organization.
In Bilbao 300 deaths could be prevented, 700 in Madrid, 800 in Barcelona,
keep adding, and that without mentioning the millions spent
on cardiovascular and respiratory diseases that could be saved.
Or the thousands of pediatric urgencies due to asthma attacks
that could also be prevented.
As you can see, our health is determined by other things
than just by health services.
Currently, we are investing very little on that which affects
our health the most.
Let's go with the second idea: What's affecting our health, and how can we
improve it?
We have seen what affects it; first of all, what we would
have to do is to invest more on what's affecting it the most.
What we do, what we eat, the air we breathe, where we live, and so on.
But it's very important to keep in our minds the entire population
and not just a few, and I'm going to explain you why, with a paradox.
It is known as the "Preventive Medicine Paradox."
In this graph you can see how any Western population
is distributed as a function of its cholesterol levels.
As you can see, most of the population
has intermediate cholesterol levels.
On the other hand, those with high or low levels are few.
This bell-shaped distribution is known as a "normal curve."
Today, most risk factors fit this "normal curve" distribution.
As everyone knows, high cholesterol levels
are harmful for our health because they are related
to a higher risk of cardiovascular disease.
The red line you're seeing represents how cholesterol levels are related
with the risk of a heart attack.
With a higher cholesterol level goes a higher risk of a heart attack.
But now let me invite you to see how deaths due to
heart attacks are distributed in this very same population.
Where do most of the cases occur?
Among those with intermediate cholesterol levels.
Why? Because even though their risk is relatively lower, there are more of them.
This is the Preventive Medicine Paradox.
A big number of people,
exposed to a small risk produces way much more cases
than a small number of people exposed to a higher risk.
As most of the population has intermediate cholesterol levels,
even though their risk is relatively lower, there will be
many more sick people and many more deaths in this population group.
And, as I was saying, this "normal curve" distribution also fits with
many other risk factors, as blood sugar levels
or blood pressure.
Today, however, where are we focusing prevention?
On those with a higher risk.
Those with high cholesterol levels will be told to change their diet
and they will get medicine.
Those with high blood sugar levels will get
their sugar consumption restricted, and they will receive medicine.
Those with high blood pressure will be prohibited to consume salt,
and they will receive medicine.
But with this strategy we're only capable of reducing, of preventing,
a small number of heart attacks, of diabetes cases,
of ictus.
And what if I tell you that it's possible to shift this entire curve to the left?
That through population strategies it'd be possible to decrease cholesterol levels,
sugar levels, and blood pressure, of everyone, not of just a few.
And this way, besides preventing more sick people and
more deaths, we would also be able of treating less people
with medicine.
The next logical question is: "OK, well, what are we going to do
to shift the entire risk factors curve?
In this example I mentioned, we could persuade people
of consuming food with a high amount of saturated fats, or sugar, or salt.
We could also promote exercise
and healthy nutrition.
I'm going to give two examples, one of each.
As you know, sugary drinks are one of the main causes
of obesity and diabetes around the world.
Some countries implemented something known as "sugar tax,"
which is a special tax over food and drinks
with excessive levels of sugar.
The United States and England are debating about it.
In Spain we're not talking about it that much, but it would not be bad
to think about some strategy of this kind because obesity,
specially child obesity, is a serious health problem in our country.
And as an example of promoting exercise
we have shared bicycle services, which already is on many cities in Spain,
for example the "Málaga bici."
In Barcelona, shared bicycle service,
which is called "Bicing," increased the use of bicycles by 30 percent
as a usual mean of transport.
But many of you will tell me that everything I'm explaining
is utopian and not realistic or practical.
I am going to give you two examples of "where there's a will there's a way."
Do you remember the lead example at the beginning?
The pressure exerted by opposing lobbies was impressive.
Oil companies had to develop new lead-free gasoline
and car manufacturers had to modify their engines.
But even so, it was achieved.
Another example: just ten years ago it was out of mind to think that
the 2011 anti-tobacco law ever to see daylight.
The opposition from the hospitality industry
and, of course, from the tobacco industry, was fierce.
Even so, it was possible to convince governments and the policy was implemented.
And today, we have evidence of the smoking reduction
and, therefore, of improved health benefits.
And as where there's a will, there's a way, I propose you
a change of perspective.
I propose you to see beyond health services
and to think about improving our life conditions, the environment,
and the society we live in.
That way, we will be able to take actions from the root of the causes.
I propose you to think beyond those few who have
an elevated risk, and to consider the entire population.
Globally.
That way we'll be able to prevent better and more.
Together, through democratic participation
we have to put pressure, to demand governments for more policies
and interventions that include the entire population.
Move, find the way, join campaigns and platforms
that are already making pressure.
Because they work.
On a local level, on your neighborhood, and at state level,
nationwide, or at international level.
Policies that improve the quality of the air we breathe,
the neighborhood we live in, our working conditions.
Policies that help us to eat and drink healthier,
and that get rid of that already known to be harmful.
And that every policy takes our health into account.
Only if we invest on the true health determinants,
only if we take action including the entire population,
only then we'll be truly able to improve our health.
(Applause)