1. Why should the public health conversation on diabetes focus more on social determinants without diminishing personal responsibility?
These two ways of thinking (individual versus communal influences on behaviour) are not opposing views, but rather are complementary. Perhaps the easiest way to communicate this is to appreciate that working across civil sectors of society can “make the right choice the easy choice” for individuals.
Over 100 years of public health science—best described by what is called the socio-ecological model of health—has clearly demonstrated that individual behavioural choices are in large part determined by forces beyond the individual. These more “structural” factors that surround an individual and a family include dominant social norms, pricing of goods and services, access to resources, environmental policies and conditions, and social policies and conditions.
Working across civil sectors of society can “make the right choice the easy choice” for individuals.
In the case of Type 2 diabetes—a disease that is a consequence of poor dietary quality, sedentary lifestyles, and stress—it is not hard to envision how such structural factors may determine diabetes risk. For example, whether there are clearly delineated and well-protected bicycle lanes in a city will strongly influence whether individuals bike to work or bike for recreation. If the per-calorie price of fresh fruits and vegetables is higher than candy or soda, then a low-income individual will be strongly incentivised to eat less healthy foods. If a child has access to a poor education, and if the society he grows up in does not regulate advertising or post warning labels, then he will be more susceptible to the aggressive marketing of unhealthy products as a result of his limited health literacy, and will thereby consume more unhealthy products. If a person has family or economic stress related to prior trauma, displacement, domestic violence or to poverty, then he or she will be overwhelmed with competing time, financial, emotional and other demands that will make “choosing” to live a healthy life (e.g., exercise daily, eat home-cooked meals, avoid addictive sugary drinks that leave one temporarily satisfied) extremely challenging.
Over 100 years of public health science has demonstrated that individual behavioural choices are in large part determined by forces beyond the individual.
The greatest evidence for the success of the socio-ecological approach to change individual behaviour of course comes from the successful War on Tobacco. Taxation, tax-supported health promotion campaigns, changing social norms (due to second hand smoke), prohibitions on indoor smoking, higher costs of tobacco products, free resources for smoking cessation etc., together led to dramatic reductions in smoking prevalence at the individual level. This helped people who smoke quit, and prevented people from initiating smoking, saving tens of millions of lives in only two decades.
In California, we have created a social marketing campaign, The Bigger Picture (www.thebiggerpictureproject.org), that connects the dots between the social determinants of health and the constrained choices that determine individual behaviours in very compelling ways, combining arts and performance with public health.
2. How can we deliver targeted and effective health literacy without the risk of stigmatising particular groups?
To begin with, insofar as Type 2 diabetes is truly a massive social problem, it is affecting everyone now, including youth and young adults. So, while risk may be somewhat more concentrated in certain subgroups than in others; however, it is still frighteningly common in lower risk groups. As such, most messages should first aim to resonate with the entire population, whereas others might need to be linguistically and culturally tailored to ethnic or economic or age-specific subgroups.
That said, I believe that successful messages will require a significant re-framing of the problem away from the usual individual “shame and blame game” (one that says that the individual is the problem; that the individual is the dysfunctional and poorly behaving one) and, rather, towards a more communal or social focus that “takes aim” at where the problem truly rests: the ways in which our contemporary societies and the systems that support such societies (food systems, economic systems, transportation systems, entertainment and communication systems, labour practices) all interact to promote this disease on a massive scale.
By targeting the environments in which we live, work, play and pray, and the social policies that determine these environments, we enable everyday people to reflect on their own situations and engage in both individual and communal actions to promote their own health, the health of their families and the health of their communities.
In other words, the problem that we should be messaging about is not “obesity and fat people”, but instead addressing the systems that promote obesity and diabetes. Our own research has shown that exposing individuals to messages about the larger systems that they are subject to not only activates them to work to change those systems, but can also—quite powerfully—empower them to change the day-to-day choices they make.
We have also learned that focusing on eliminating Type 2 diabetes in youth and young adults—whom everyone can agree have no business getting “adult-onset diabetes"—is an effective communication strategy with which to engage the public, and promote structural and behavioural interventions that are both good for youth but can also benefit everyone.
Exposing individuals to messages about the larger systems that they are subject to not only activates them to work to change those systems, but can also—quite powerfully—empower them to change the day-to-day choices they make.
3. Given competing interests, how can we convince different stakeholders to work towards a common goal of preventing diabetes?
Type 2 diabetes can no longer be viewed as just a medical problem, but as a deeply engrained social problem. If we only focus on healthcare providers and health professionals, we may win a battle here and there, but we will lose the war. To actually win this war, we need deep engagement and innovation from many sectors of society coming together to promote “Health in All Policies”1: the transportation sector, the parks and recreations sectors, the entertainment and communication sector, the food and beverage industry (to change what they produce and market), the finance sector (to determine and implement incentives and disincentives), the legal and regulatory sector, the educational system, the labour sector (to promote less sedentary work styles), etc.
Singapore—with its highly functional and cross-disciplinary civil service institutions and professionals and innovative spirit—is well-positioned to show the world how to leverage all sectors of society—public, private and civic—to dramatically reduce the impact of Type 2 diabetes on a nation’s well-being and productivity.
Type 2 diabetes incurs high costs to the public and private health care sectors (and to the businesses that often pay for health insurance), given the large extent to which the disease contributes to lower work productivity and early disability, and given the significant caregiving burden it places on families. It should not be difficult to engage a broad range of stakeholders to combat it. There may be certain industries, especially those that currently benefit from the status quo, that actively resist efforts at effecting change. But the fact that Singapore, from the very top, has declared war on diabetes, is a critical start.
Singapore's War on Diabetes
According to the Health Promotion Board, you can BEAT diabetes with a 4-step plan:
Quick Facts on Diabetes in Singapore
Did you know:
ABOUT THE AUTHOR
Dean Schillinger, MD, is Professor of Medicine in Residence at the University of California San Francisco, and Chief of the UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital (SFGH). Dr Schillinger served as Chief of the Diabetes Prevention and Control Program for the California Department of Public Health from 2008–2013. He is an internationally acclaimed researcher in diabetes-related public health and health literacy, and the co-founder of TheBiggerPicture.org, a social marketing diabetes prevention campaign to empower minority youth to change the conversation about diabetes and become agents of positive social change.
- Linda Rudolph, Julia Caplan, Karen Ben-Moshe, and Lianne Dillon, Health in All Policies: A Guide for State and Local Governments (Washington, DC and Oakland, CA: American Public Health Association and Public Health Institute, 2013), https://www.apha.org/-/media/files/pdf/factsheets/health_inall_policies_guide_169pages.ashx?la=en&hash=641B94AF624D7440F836238F0551A5FF0DE4872A.