Measuring Wellbeing…or something like that

The epitome of wellbeing

So, the government wants to measure our wellbeing. Aside from making headlines that divert our attention away from the massive public sector axe that is falling heavily, this is a genuinely interesting proposition. Whilst some might question the wisdom of seeking to do this at a time of economic gloom and severe austerity measures, the recent move is the result of an idea that has been gaining political momentum over the past few years: the idea that economic prosperity alone does not constitute progress in a nation’s development. The wellbeing of the people is also important. A rich nation (measured by GDP) of thoroughly miserable people is not necessarily better off, all in all, than one with lower GDP but greater levels of “wellbeing”. Furthermore, Cameron’s idea is that it is the business of government to be interested in the nation’s wellbeing and to seek to promote and maximise it. Indeed, he wants to place wellbeing at the heart of policy-making: striking indeed coming from a Conservative Prime Minister. Tony Blair attempted the same feat, only to admit defeat and let it quietly slip off the policy agenda when the idea proved too complex to implement. Which brings us to the key question prompted by my vague description thus far: what on earth is wellbeing and how could or should we measure it?

Numerous indices of wellbeing have been developed, with increasing degrees of sophistication, reliability and statistical power. Broadly speaking, these indices take the form of questions about how a person feels about his/her life, answered on a rating scale. They cover areas including health, education, work or employment, family life, activities, community and social connectedness, political voice and governance, insecurity, environment and the rather ambiguous “subjective wellbeing”. The World Health Organization’s wellbeing questionnaire is somewhat simpler but taps into what we might consider is the essence of this last area, referring to positive mood, calmness, vitality and interest in daily life.

The difficulty with attempting to operationalize an abstract concept such as wellbeing through the development of quantitative measurements is the inherent subjectivity of those measures. To take but one example, pertinent to our work here at CHH. Let us suggest, quite plausibly, that health is considered to be a key component of wellbeing. A survey polls a group of people on their state of health and these statistics feed into a compiled wellbeing score. On this simple view, poor health would look like an inevitable detriment to wellbeing. However, several disparate research literatures point towards a more complex relation between health and wellbeing, or lack thereof. The recovery movement in psychiatry, for instance, promotes the idea of nurturing and enhancing subjective wellbeing in circumstances of chronic mental illness. Although ‘recovery’ is not a concept that can be captured in a soundbite, the kernel of the movement is about learning to cope with and manage one’s symptoms and distressing experiences, in order to regain control of one’s life and thus achieve a state of wellbeing. Havi Carel, a philosopher in Bristol, has written extensively on the idea that one can be ill, even terminally so, but happy and content with one’s life. Indeed, the narrative structure of many survivor accounts of various illnesses demonstrate a journey towards reconciliation between a prolonged state of poor health and a sense of personal wellbeing. This is not to suggest that health and wellbeing aren’t related, only that health status shouldn’t be assumed to map on to wellbeing in such a straightforward manner. This example is just the tip of the iceberg in terms of the conceptual complexity any measure of wellbeing will have to deal with, and it will be interesting to see what the statisticians come up with. I hope to post more on this topic as the measures are developed and reported on.

It's all a bit complicated....

Obesity: the causes behind the causes

There is much talk about the causes of obesity and about responsibility for health. But what gets discussed little – far too little, in fact – are the causes behind the causes: agricultural policy and economic interest.

Read the New York Times‘ fascinating article that explores the US government’s role in the marketing of high-calorie junk food. The brief story is this: reductions in countrywide milk consumption as well as an increased demand for low- and non-fat milk (people watching their diets maybe?) have resulted in excesses of milk-fat. These excesses need to be sold – in other words, eaten. The easiest and fastest way to eat milk-fat is in the form of cheese, therefore the US department of agriculture has created a marketing group called ‘Dairy Management’. Dairy Management works with junk food sellers and producers to encourage them to add more cheese to their products.

Yes, that’s where those appealingly melting cheesy pizza crusts come from!!!

In other words, the US government simultaneously promotes healthy diet through fat-reduction, whilst subsidising the invention, marketing and sale of high calorie, cheesy food varieties. As a result the very same person that is diligently attempting to cut calories and fat-intake by changing to low fat milk may be unknowingly reingesting all that extra milk-fat, or even more, by buying a subsidized pizza slice containing 40% more fat and calories that it did before.

I hardly need to point out that the people shopping at Wholefoods (the US’s upmarket organic supermarket) are unlikely to find their favourite foods insidiously enhanced with cheese. The people that will end up disproportionally ingesting the excess milkfat will be a familiar sounding lot: the ones that have little education or awareness, little time for cooking and shopping – if a supermarket is even accessible to them – and little health insurance. These very same people will often be feeding a family.

We can talk about ‘health promotion’, ‘life-style change’ and ‘responsibility for health’ till the cows come home. But as long as countries continue to produce more food then they need, and as long as they continue to insist on forcing that food down the throats of their own population, with the full force of government subsidy and industrial marketing behind it, individuals and health promotors are doomed to fight a loosing battle. I do not deny that, ultimately, individuals have freedom of choice. But at the moment the powers that are very much conspire to stack the deck in favour of certain choices only. And, as ever, the further down the socio-economic ladder you go, the worse the deck becomes.

For more, do read the article, it is absolutely fascinating. Note also the conflict of research interests described.

For a similar story about corn, Michael Pollan’s Omnivore’s Dilemma gives a very accessible, if popularized, analysis, explaining at once why processed food (in the USA) is so cheap, and why the consumption of soft drinks has spiralled up; soft drinks are the easiest vehicle for getting a population to consume more corn. The corn industry keeps increasing it output at decreasing profit margins, and continues to be heavily subsidized by the US department for agriculture.


Alcohol vs. Heroin: What’s the Harm?

If the headlines are to be believed, a recent paper in the Lancet claims that alcohol is more harmful than heroin. The reaction to this claim by most commentators has been sceptical to say the least: in what possible world could this claim be true?

First, some context. The paper’s lead author, Professor David Nutt, set up the Independent Scientific Committee on Drugs after being sacked from his advisory role by the previous Labour government. He has been a longstanding critic of the government’s approach to drugs and drug policy, arguing that it is based not on scientific advice or evidence but rather political ideology. It is therefore perhaps unsurprising that his latest research aims to undermine the basis of the government’s stance on ‘hard drugs’, in this case by pointing out that in fact the legal drug, alcohol, does far more damage to both users and society at large.

The interesting question (for a philosopher at least) is: what does Prof. Nutt mean by ‘harm’ here? Two distinctions need to be made in order to get a handle on this. Firstly, harm to whom? This is addressed in the paper by distinguishing between harm to the user and harm to others. Heroin, crack and methamphetamine cause the greatest harm to the individual user, but alcohol tops the list for cumulative harm to the user and to others.

This seems counterintuitive: many of us enjoy the odd tipple, occasionally even drinking to excess, without causing harm to ourselves or to others. This is where the second distinction comes into play, and it is not made particularly clear by the Lancet paper itself. This is the distinction between public health and individual health. The paper is concerned with the public health implications of the consumption of these drugs, i.e., its interest lies in the point at which their use becomes an issue for health (and social) services at an epidemiological level: the analysis of harms conducted “rang[es] from the intrinsic harms of the drugs to social and health-care costs.”

Clearly for most of us our drug habits do not concern health services at all. But at the point at which they do, the harm implications of alcohol consumption become much more evident: risks of liver cirrhosis, cardiomyopathy, losing one’s job, family breakdown, criminality etc.

There is no doubt that heroin use causes huge harms to the individual user and to society, but at an epidemiological level, these harms are dwarfed by the scale of the problems of alcoholism in this country. Estimates from the Institute of Alcohol Studies suggest that based on statistics from 2000, around  3 million adults in the UK are alcohol-dependent.

2 factors therefore combine to justify the intentionally provocative conclusion that alcohol is more harmful that heroin. Firstly, the ‘harms’ recorded are those which fall within the domain of health and social services. This excludes the ordinary drinking habits of the vast majority of ‘social’ drinkers. Secondly, as a public health issue, the scale of alcoholism or alcohol dependence as compared to heroin addiction does entail that alcohol causes greater health and social problems than heroin in this country. But I guess with those caveats the headline doesn’t sound as snappy.