Economics of Public Health blog series - a comment from Dr Alan Shiell

Being an economist in public health has, for a long time, been a lonely place to be. With a few exceptions, my colleagues made their fame and fortune and often both in the more glamorous and far better resourced field of health care economics, where drugs and machines and surgical techniques made for relatively easier subjects for economic evaluation. It’s great therefore to see public health economics becoming mainstreamed largely on the back of the scrutiny coming from NICE and the MRC. I welcome this blog and am looking forward to engaging in the ongoing debate and discussion that it will foster. And while I’ll probably agree with 90% of what Cam and his colleagues write, I’m going to focus my comments on points of difference if only to get some discussion going.

And where better to start than scarcity – the sole rationale for the existence of economics.  I’ll leave values for a later response.

But first a confession. Cam and I studied together. Actually we lived, played and got drunk together as well. I have the same slides, the same stories the same intellectual debt to the masters of our field – Alan Williams, Tony Culyer and Alan Maynard especially. I preach the same mantra – resources are scarce, scarcity means choice, choice means opportunity cost. I’ve been teaching it for 25 years … and I believe it – largely.

Each time I give the scarcity lecture I invite the audience to challenge the assertion. None have, except once (a testimony to the power of the presenter not the power of his ideas).

On this occasion a woman put up her hand, interrupting me in full flow, and asked me to look out of the classroom window onto the street scene playing out below. People were going about their everyday business, some working, some shopping, some recreating. Some were in groups talking to each other, on the street, in cafes. Some walked, others were cycling, yet others were in cars or buses. A postie delivered the mail checking the welfare of the elderly resident, a shop-keeper acknowledged a presence with a smile, people moved aside to allow someone in a wheelchair to get by, a door was held open for a woman with a baby. This is the cute description, but equally, there were people alone, who were ignored, abused, people whose path was obstructed, who did not receive help when they needed and so on. That’s not the point. The point was, said my interrupter, that if we really believe in the social determinants of health then all resources are public health resources, everything contributes to public health – physical activity, social connectedness – everything is a resource. In which case, she asked, can resources really be described as scarce?

I gave my standard response. Yes, I said, resources are still scarce, but not in any absolute sense, just relative to all that we can do with them. But this misses the point. Scarcity arises not through the personal choices of isolated individuals – Robinson Crusoe’s stranded alone in a hostile natural world – as the economics text-books would have us think, but from deliberate public policies and social institutions. Ted Schrecker makes the point much better in his paper “Denaturalising Scarcity”. Ted points out that the 500 deaths caused by the 1995 Chicago heat wave followed a highly predictable social pattern as did the many more victims of hurricane Katrina. The less well off your neighbourhood, the more likely you were to die, and this in a country that can afford to give everyone a decent standard of living but chooses not to. The victims of hurricane Katrina did not die because of a personal predilection for tobacco, slovenliness or fast food, but because of differences in political power that prefers tax cuts for the rich over a liveable wage for the poor.

The practice of economics remains largely blind to such differences. And for as long as it continues to do so, for as long as it ignores politics and power and for as long as it priviliges efficiency over equity, relegating the latter to a second class consideration, it will be mistrusted and marginalised by people in public health. I still believe that economics can improve population health and reduce inequities, but not if it continues to see public health as just another type of health technology.

Alan Shiell

Centre of Excellence in Intervention and Prevention Science

Melbourne, Australia