Public health is all about managing the health of a population. The driving forces are really not intended to manage an individual’s health.
Individual health management is tailored to the individual but almost never translatable to managing a healthy population.
If you think about the last time you went to the doctor and were prescribed a treatment, you understand that it would be very strange to say ”that treatment was good for me so the whole population should have it”.
Well orchestrated lockdowns during the early stages of the Covid pandemic successfully reduced the the death toll in Australia. We had a negative “excess death rate” for 2020 and 2021. That is a fantastic public health outcome. However the wellbeing of some individuals was actually negatively impacted by lockdowns. It was a great decision for the population and turned out to be a really bad thing for some individuals.
Getting your head around how public health and individual health priorities are different and often collide turned out to be very hard for people during the pandemic and fuelled most of the social unrest that we saw.
With Public Health initiatives it is expected that a small percentage of individuals will opt out or will be unsuitable due to their individual health requirements, but Public Health initiatives do not need 100% compliance to work.
I suspect that there are many systems that this collision of priorities creates unrest.
As many of you know I co-founded a Neonatal Kitten Rescue Hobart. We rescue tiny kittens who are unable to feed themselves. These vulnerable waifs and their stories have amassed a big following and a small army of supporters. The not for profit is financially sound and the work which is all done by volunteers is highly regarded.
But, the cat is classed as an invasive species in Tasmania. Despite 200 years of integration into the Tasmanian eco system it is still demonised by many, and mass cullings are randomly undertaken despite poor evidence that such actions will achieve anything.
Rescue is an individual welfare issue and the Tasmanian ecosystem is a population issue and the forces commonly collide. There are also lots of factional groups competing on the interest of one species over another. I have recently discovered that the Sugar Glider, while native to Australia is introduced into Tasmania and is decimating the swift parrot population be eating nestlings and their mothers as they sit on eggs. Culling cats increases sugar gliders and decreases swift parrot females, which are usually monogamous but are now having extra marital affairs due to the excess of males. It is complicated.
The muddied water that is mental health policy is a similar area where competing forces have had bad consequences. We have seen interventions driven by population data impact terribly on individual mental health time and time again. The cashless debit card is the most recent train wreck here in Australia.
The right intervention for an individual many times takes them out of the workforce which is bad for the population. Theres a book called “Sedated: How modern capitalism created our mental health crisis” which looks at this issue of tying work productivity to DSM categories. What can seem like an innocent distinction for the clinician to make is painted in a new light as a noxious force in the capitalist machine.
Clinicians see daily how interventions that work with individuals are just not translatable to the masses. The idea that they might translate fuelled 60 years of stagnation in the field of psychotherapy. Many therapists with skills in marketing and good intentions ran with their personal discovery from working with a few clients, a new technique that they thought would work for the masses. Lots of TED talks were had, keynotes and conference tours with no improvement in outcomes in population mental health and possibly even more alienation of the poorer socio-economic cohorts who suffer the most.
The clinicians that I admire rose a little on that wave and didn’t like what they saw, choosing to return to the basics of foundational teaching and focusing on doing good work in the full awareness that there is something seriously missing in the field but until we find it we can focus on doing good work with individuals and working on being available to the more disenfranchised cohorts.
There is something very humbling about working in a time that we will look back on as a profession with embarrassment. We know we will look back with shame on things like human rights violations of psychiatric inpatients, on medicating children without knowing what the drugs we use actually do on many systems. On receptors that we know exist outside the brain but we have little understanding of what they do there. And yet doctors still prescribe.
SSRI product information contains a warning that the drug increases suicide risk in under 25’s. It has had this warning for my whole career and prescriptions continue to be written and under 25’s on SSRI’s continue to suicide. And yet doctors continue to prescribe.
Neuroscience, the golden child of the ’90’s has also not delivered. We could say it’s in it’s infancy, but after 30 years of intense study and no improvement in outcomes for people, it is more likely that its basic fundaments are flawed. The observations are very gross. For me its like saying ohhh you went to the gym and did arm curls and now you have big biceps. The big biceps must have made you go to the gym and do arm curls. You must have had a genetic predisposition in your biceps that predispose you to go to the gym. I read any neuroscientific observation through that lens to help keep things real. There are way too many dodgy semantic links between two observations being made.
So why the meandering on this sunny winters morning in Tasmania, 42 degrees South, when I haven’t written a blog for so long? There isn’t enough written on how badly we are doing with mental health. Theres not enough gentle questioning of the foundations we take for granted that must actually be flawed for such monumental inaction to have been the norm. Gandhi said a long time ago that you can’t change anything without a newspaper, I am a fan of conversations for possible conversations. we don’t know what we don’t know.
For me, I think management of suffering has been too much in isolation for the last century. Healing always used to happen in community. In large group rituals. Making it a one on one thing in a clinician’s consult room was such an odd thing to do.