Individual triumphs can lead to policy change

The first of these was a college roundtable event, looking at paediatric engagement in about 23 countries. Discussion moved between the technical skills doctors bring to work overseas and the wider advocacy issues such work entails. It is that simple comparison between helping the individual and solving the wider societal problems that the reforming 19th century socialists Sidney and Beatrice Webb characterised as pulling people out of swamps as opposed to draining the swamps themselves.

It is played out daily in all aspects of UK childcare. Social workers, for example, are responding to individual need, reduced welfare benefits for their clients and smaller local authority budgets, when these very pressures are the result of government policies. I have often been struck by the thought that the most effective way of intervening in the lives of many families who are social services recipients, would be to become a housing manager. The effects of the social engineering that placed tens of hundreds of families on sink estates was far more corrosive and powerful than any compensatory intervention by a local social work team.

To go back to the starting point, the ebb and flow of individual help – as opposed to campaigning and advocacy – is played out by doctors in large development programmes, desperate to save malnourished children while the causes of the famine remain untouched.

The second occasion where this was recently brought to light for me was Richard Wilkinson speaking at the college about the findings of his influential book, The Spirit Level: Why Equality is Better for Everyone (2010).

In the equation outlined above, Wilkinson would come down firmly on the side of wide-scale social interventions. As well as some telling comparisons between the very richest and poorest people in Western societies, his central thesis is that health and social problems are worse in more unequal countries – if this is measured according to factors such as life expectancy, literacy, obesity or mental health.

Wilkinson has some stark examples. Child wellbeing is greater in more equal countries such as Sweden, Finland or Norway, as opposed to the UK or US. People in more unequal countries tend to trust each other less. Within the US, the more unequal states trust each other less. Mental illness is more common in the more unequal societies and infant mortality rates, not surprisingly, are higher in more unequal countries. Lastly, if we look at social mobility or imprisonment rates, we again find that the more unequal the society, the less social mobility and the more people in prisons.  Where Wilkinson is particularly astute is in the book’s subtitle – Why Equality is Better for Everyone. For those at the top, opposed to any redistribution of money or other resource, he argues that the benefits of greater equality in any society are not simply confined to the poor, but extend to all social classes.

The answer to this ebb and flow between individual intervention and wider social engineering is that it is a false dichotomy.  You need both. Globally, medicine has traditionally been very strong at demonstrating the effectiveness of individual intervention. While senior international aid workers battle with health ministers in developing countries, the doctors on the ground continue to save lives. And, of course, the evidence for change is provided by individual examples.