From the point of view of early diagnosis, treatment, and support for survivors, the new National Cancer Strategy 2017-2026 is an excellent document. However, the prevention section is a big disappointment. According to the foreword by the Minister for Health, Simon Harris, “cancer prevention is a cornerstone of this strategy as it offers the most cost-effective, long-term approach for cancer control”.
Prof John Kennedy, chairman of the steering group that put the strategy together, also stresses the need for prevention and aggressive programmes of public education and “that the most strenuous efforts must be made to target more deprived populations in cancer prevention”.
Although recognising the “incontrovertible evidence of the enormous impact of socioeconomic status and deprivation on death rates from some cancers Ireland”, he blames smoking and poor diet. In fact, the prevention chapter is all about the promotion of healthy lifestyles. This approach will not prevent cancer or reduce inequalities.
Did the members disregard the evidence that inequality and health inequality are the main cancer risk factors? No, they knew about the health impact of inequality. “Reducing health inequalities is a priority of this strategy, as lifestyle risk factors generally follow social, deprivation, gender, and age patterns.” The steering group included a representative from the National Cancer Registry which produced a report on cancer inequalities last year titled Cancer Inequalities in Ireland by deprivation, urban/rural status and age: A National Cancer Registry Report 2016.
This report showed that not only was there a higher incidence of cancer in deprived populations but these populations had much lower survival rates. “Strong patterns of inequality . . . are documented for most of the measures examined [nine major cancer types].” None of the proposed prevention actions in the new cancer strategy will reduce inequality and may widen the health gap between socioeconomic groups. It is more likely that the steering group recognised the impact of inequality but did not know what to do about it.
There is overwhelming evidence that focusing on getting the lifestyle message across and public health education does not prevent cancer or any other disease. Prevention groups know that poor people get sick more often than those who are better off but do not analyse the problem. They assume it is a health education issue and believe that if only “the poor” realised that smoking, drinking, and being overweight was bad for their health they would change their behaviour. Because of this erroneous belief, health professionals, the Department of Health and the HSE rely on health information campaigns. They believe that if they say it often enough people will change.
For example, Goal 1 in the National Cancer Strategy is directed at reducing the cancer burden by focusing on health inequalities through information campaigns. “A significant effort is required to ensure that prevention and awareness campaigns have a particular focus on addressing health inequalities” and “it is vital that we are effective in getting the message across to the population that each person can impact significantly on their own level of risk of developing cancer.” This is so stupid.
According to Margaret Whitehead, a World Health Organisation expert on the social determinants of health and health inequalities, “the solutions may seem so complex that people can easily become frozen into inaction” leading to “lifestyle drift.” In 1988, she wrote The Health Divide which analysed the huge differences in health between socioeconomic groups.
According to a 2016 paper by Whitehead, the reason poor people do not adopt healthy lifestyles is because they do not control their own destiny. “Being in a low social position; living in a disadvantaged environment with a sense of collective threat and powerlessness and the degree to which people are discriminated against and excluded from the society in which they live”, means that people are more likely to develop cancer and other chronic diseases.
According to the new cancer strategy, “As more evidence emerges regarding the development of cancer . . . there will be a need to identify the most effective prevention methods.” We already know the most effective method which is to reduce or, as far as possible, eliminate inequalities and thus health inequalities. Unless this happens the numbers of people with cancer will not just double by 2040, as predicted in the National Cancer Strategy, but treble.