Professor Alan Maynard OBE examines the determinants of lifetime health through the prism of the ‘Bard of Hull’ Philip Larkin’s best-known poem.

The ‘experts’ are predicting that many children born in 2010 will live for a hundred years and more provided the population is not cropped by Malthusian war, diseases and famine (and earthquakes and volcanic eruptions!).

It is generally agreed that that the major determinants of health are genetic endowment and individual behaviour. Healthcare (the rescuing of citizens after they have fallen into the river of illness) has a significantly beneficial but much smaller effect on population health.

The role of genetics
“They fuck you up, your mum and dad”
Philip Larkin (1922-1985), This Be The Verse

Perhaps Larkin, in his discussion of your inheritance of the faults your parents, was more focused on inter-generational transmission of behaviour and social mores than on parental genetics determining your life chances.

Gradually increasing knowledge of genetics will make the discussion of eugenics fashionable again, so that our offspring may inherit fewer of our defects in genetic make-up.

The selective breeding of human beings was much discussed in the early twentieth century. Many well-known names were involved in these discussions, including the economist John Maynard Keynes, the social reformer William Beveridge and novelists and opinion makers such as George Bernard Shaw.

Eugenics? Oh, kneel!
The statistician and scientist Francis Galton’s approach to eugenics focused on social class rather than race. In a famous lecture, he divided British society into those of less and greater “social worth”. He favoured “negative eugenics” which involved attempting to prevent “undesirables, criminals and paupers” from having offspring and “positive eugenics” which encouraged the professions, employers and other desirables to breed.

Galton was of the opinion that once the population saw the virtues of positive eugenics and the “improvement” of society it would create, human behaviour would lead to selective breeding.

Debate around these notions ceased due to National Socialism and the Nazi’s slaughter of Jews, gypsies and the intellectually handicapped in concentration camps (a “facility” invented by the British in the Boer War).

The rapid development of genetics is reaching the legal limits of current ‘ethical’ policy. But is creating embryos by using genes from different people - thereby avoiding inherited fatal diseases in offspring - going to create public debate and more liberal criteria for genetic manipulation i.e. eugenics?

Whilst a parent might like this innovation to acquire a healthy child, what are the limits for such social experimentation? I do not offer any answers to such questions. However, the broadening of this debate, and the return of discussion of issues raised by Keynes, Beveridge and others, seems inevitable.

The genetic revolution will affect population health with new treatments. As ever the pharmaceutical industry will seek to patent these and make money.

Hopefully, the judiciary will inhibit the drug dealers from patenting natural substances e.g. recently a US judge overturned patents on breast cancer genes because they were products of nature (BMJ 10 April, page 780).

The role of behaviour
“The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d rather not”
Mark Twain (1835-1910)

Whilst genetic knowledge and policy ferments, the equally long-running debate about individual behaviours is likely to erupt with increasing vigour.

’The public health fig-leaf also creates an incentive to spend more on the NHS and invest in interventions which all too often add little health gain for patients - but are worth big bucks to the medical professions and the ‘ethical’ drug industry.’

When and by how much should we limit the efforts of the alcohol industry to create social mayhem and liver disease and other illnesses?

When and by how much should we limit the efforts of drug dealers complementary to alcohol in the tobacco trade?

When and by how much should we prevent the purveyors of sugary drinks and junk food be prevented from creating more obese children and adults, who will rapidly progress to diabetes and heart disease?

We can note that sadly, these issues, like the economic effects of the recession, are not being debated systematically (rather than rhetorically) during the current election campaign! The reasons are obvious.

These purveyors of good things we like to use to abuse our health are major employers, and also have been known to offer moral and financial support to particular political parties.

So the policy seems to be ‘let’s carry on messing up citizens’ lives so that when they are ill they can keep NHS operatives in the style to which they are accustomed’!

Perhaps there is a better way?

For decades, the political parties have trumpeted the virtues of public health and invested millions in it. This virtuous fig-leaf nicely disguises the politicians’ desire not to annoy supportive and licit drug dealers and those anxious to meet our desires for sugar, salt and fat.

The public health fig-leaf also creates an incentive to spend more on the NHS and invest in interventions which all too often add little health gain for patients - but are worth big bucks to the medical professions and the ‘ethical’ drug industry.

‘If we want to improve population health, income redistribution and improved educational opportunities would probably give a better bang for the buck than more hospitals, more doctors and more nurses. If we want to give the young good lifetime health, we need to invest in their early years.’

Conclusions
If we want to improve population health, income redistribution and improved educational opportunities would probably give a better bang for the buck than more hospitals, more doctors and more nurses.

If we want to give the young good lifetime health, we need to invest in their early years - which compensate for your mum and dad fucking you up by their behaviours, choices and genes.

But such radical notions are as unlikely to be exploited as our being offered a real election debate of core economic issues by our chosen political representatives!

P.S. Congratulations to big pharma for getting David Cameron to pledge funding to cancer drugs that NICE considers a waste of public money.

So much for evidence-based policymaking, eh!