The Miracle Pill

by Peter Walker

  Kelly gives an even higher estimate for the proportion of his patients brought to the hospital with conditions caused in part from inactivity. During an interview which begins as he strides back to his office in the top levels of the hospital, me half-jogging alongside, audio recorder held hopefully in the air, Kelly spends at least five minutes verbally mulling this over. ‘Now there’s a question,’ he begins, launching into a response that takes in subjects including eighteenth-century economist Adam Smith’s ideas on the specialisation of behaviour and the legacy of Margaret Thatcher. Eventually he comes up with a figure: anything up to 60 per cent. Pausing some more, he adds: ‘In fact, if I was to go through the current ward I think it would be more difficult to find patients for whom inactivity is not an issue. Of course, I’ve got a skewed population. I’m an adult physician in a central London teaching hospital with a lot of racial, economic, political and religious variation. But I can’t think of one at the moment.’

  Kelly is adamant that unless things change, then the NHS as he knows it, universal and free at the point of use, will not survive. ‘We cannot stand still as things are,’ he explains. ‘And it’s not even about standing still. So what gives? The short answer is: the way things are at the moment, which is fragile anyway, cannot be maintained. Our skill at keeping us alive to present later with more conditions and more medications is unsustainable. I don’t say that as a failure of what we do to keep people alive. The tap is being turned on more and more and more, and no one is doing anything about the plug hole. But it’s not medicine that’s causing the problem, it’s public health.’

  Those tasked with surveying the health system from a broader perspective have reached the same conclusions. Dr Justin Varney, formerly head of adult wellbeing for Public Health England, who is now in charge of public health for the city of Birmingham, tells me: ‘I think people are realising that the whole concept of an NHS and welfare state, in whatever form we have it, is completely unsustainable if a third or more of the population remain physically inactive.’

  This is, he says, as much an issue of overall national economic viability as just about health services. ‘The problem of inactive lives is growing, and I think we’re understanding now much more clearly the direct correlation between inactivity, population health and economic sustainability,’ he says. ‘It’s not just that being inactive contributes to over twenty-four long-term conditions, it’s also that if you’re inactive you’re more likely to be socially isolated, you’re not likely to be part of the job market and achieving your full economic potential, and although you may well be living longer in terms of total years of life, you’re going to be living more of those years with ill-health and impairment, and therefore require much larger demands for social care and support, as well as not having the happiest retirement.’

  The population-wide consequences of this are almost incalculable, Varney says: ‘In the context that a third of kids today will see their 100th birthday, we fundamentally cannot afford to continue with the legacy of inactivity, because those children would live a life in which potentially forty years is lived with chronic disease, and that will break the system. Certainly in the context of the UK welfare state it’s completely unaffordable. But also from the context of business, those people will need to remain economically in the job market well into their seventies, and in order to work you need to be physically active.’19

  Such problems do not just affect the UK, or even similarly sedentary developed nations like the US and Australia. Fiona Bull is an inactivity expert with the World Health Organization, and was one of the co-authors of the landmark 2012 Lancet study which revealed how widespread it now is around the world. Bull notes that the United Nations runs regular high-level summits on the problem of lifestyle-connected diseases, particularly for poorer countries, where people are also living longer but with more ailments, many connected to the loss of activity from people’s lives, whether from changed jobs or the growth of motor transport.

  ‘The burden for non-communicable diseases is a burden that is unsustainable and will cause great pressure on the current health systems, not to mention fragile health systems in developing countries,’ she says. ‘You simply cannot provide enough medication and healthcare services for these chronic diseases at the volume that we are creating through the lifestyles people lead, and the failure to deal with the risk factors.’

  Again, this is not just about inactivity. A range of other risks exist in various regions, for example efforts by tobacco giants to market their products in Africa amid declining sales on other continents. Children are also growing up more overweight than their parents, as well as less active, Bull notes: ‘There is a clustering of risk factors in these younger age groups which is unprecedented. It’s going to lead to even more diseases, which healthcare systems will be required to handle. And we can’t afford it. No country can afford it.’20

  Of Bull’s four major risks for NCDs, tobacco and alcohol abuse are relatively easy to untangle. With inactivity and obesity, they are often combined, not least because of their joint contribution to one of the major chronic health burdens of the era: type 2 diabetes. As Jonathan Valabhji, who has spent nearly thirty years helping people with the condition, says: ‘If you’re asking me, “I’ve got someone with a new diagnosis of type 2 diabetes, what percentage of the determination of their onset is attributable to diet and what to exercise?” No, I can’t give you that, and I don’t think anyone can.’

  The graph of doom

  There is a second, hugely important strand to this story of inactivity and the social and economic costs it imposes on countries. This is looking after vulnerable older people, otherwise known as social care, which is simultaneously one of the most pressing and more neglected political issues of our times.

  In health terms, it is simply a time-based extension of the effect of millions more people simultaneously living longer lives but developing chronic illnesses and conditions, many related to inactivity, at younger ages. At some point, many are no longer able to care for themselves.

  This phenomenon is being witnessed across the world, but it is particularly acute in wealthier countries with ageing populations, such as the UK with its increasingly wide gap between healthy life expectancy and overall life expectancy. Of course, this is an average figure, and by no means every person aged over sixty-five, or even those aged over eighty-five, are unable to live independently. But millions of older people in the UK do need assistance – everything from occasional help in their own home, to regular visits, or then life in a residential care setting. In many cases the work is done by relatives, which while unpaid has a huge economic effect, as carers are often left unable to do other jobs. Some wealthier older people pay for support.

  But that leaves an enormous and increasing burden on the state social care sector, provided as a legal obligation by increasingly cash-strapped councils, which have seen their central government budgets slashed in the past decade. Some of the obligations cover social care for vulnerable children, but the great majority of the cost is for older people, and it is hard to overstate how much of a financial challenge this has already become. I can remember speaking to the leader of one English council, who told me that in just five years, the costs of social care in his borough had risen by 25 per cent. Another English council, in 2018, had to formally declare it could not meet its obligations.21 The impact of the Covid-19 pandemic on people living in care homes illustrated the strains felt on the sector, with the virus often spread between homes by agency staff working long hours in multiple locations. Councils and care providers are still awaiting a long-promised UK government plan for the sector. The situation is the same in many other countries.

  The scale of this challenge was laid out a decade ago by something known – in all seriousness – as the Barnet Graph of Doom. Renowned by those who have heard of it as one of the more frightening PowerPoint slides ever created, it was the work of Andrew Travers, who at the time was the head of finance for Barnet
council, on the northern fringes of London. The horizontal axis has a rising series of bars showing the combined cost of adult and child social care for Barnet over time, both historic and projected a decade or so into the future. The vertical axis, represented as a line, shows the total budget for the council. At some point in the 2020s, they meet. This would mean the entire budget used up for social care, with nothing left for anything else – libraries, parks, bin collections, anything.

  There is, of course, a good argument that the graph represents an oversimple extrapolation of current trends, but the point is eloquent. Travers now works at another London council, Lambeth, where I talk to him. The Graph of Doom, he concedes with some pride, remains well known ‘in rarefied circles’, and caused a brief fright among ministers. ‘Central government heard about it because people rang them to ask, “Is this right, is the end of the world coming?” ’ Travers recalls. ‘Once it did get that wider currency we were keen to say that it wasn’t necessarily predicting precisely what will happen. But we were trying to explain a narrative that we believe to be true, i.e. the fundamental difficulty of reducing resources and increasing demand, just to make that clear to people. And it succeeded quite well in doing that.’

  Travers also makes the point that the crises in the health and social care system are not separate, in that many older people who go to hospital have to be discharged into some form of care – and if that does not exist, they cannot leave. This could soon bring a year-round shortage of hospital beds, he predicts: ‘It wouldn’t just be a winter NHS crisis – you might see it in the spring, and the autumn.’22

  What is the connection to inactivity? It is because, as we’ll see more fully in a later chapter, staying active as you age is a huge predictor of how likely you are to remain healthy and independent. Regular physical exertion has been shown to affect everything from strength and balance (and thus the likelihood of falling) to bone mass and cognitive ability, as well as the risks of developing all sorts of debilitating illnesses. To borrow the Ralph Paffenbarger maxim: ‘Anything that gets worse as you grow older gets better when you exercise.’ Or, as one public health expert once put it to me, more bluntly: ‘I tell people, “Being active throughout your life is about being able to get to the loo on time in your old age.” They can get their heads around that.’

  Numerous studies have backed this up. One ongoing US-based project reported in 2014 on older people and their ability to walk unaided, a key factor of independent living. It involved around 1,600 people aged seventy-plus whose fitness was tested as low, but could still walk 400 metres. They were split into two groups, one of which was put through low-level physical activity, with the other given workshops on better ageing and some stretching exercises. In a follow-up just two and a half years later, significantly more of the latter group had problems walking longer distances than those who had undergone the activity programme.23

  The results reinforce one of the lessons I have picked up while researching this book: if you are ever a test subject in a public health trial, and one of the intervention options involves physical activity, do whatever you can to end up in that group. These decisions are usually randomised, but try to bribe a researcher to fix it. You’ll benefit in the end.

  Better without medicine

  As we’ve seen already in the book, simply telling people they should move more is not enough. The same is true even when the people telling them are doctors. For all that doctors are often the first person to break to someone the consequences they face due to decades of inactive living, even the most passionate physician cannot single-handedly dismantle the societal pressures people face, assuming they had the time.

  Asked if it can be a depressing experience to simply help people manage preventable conditions, Martin Whyte agrees. ‘I do find that,’ he says. ‘I put it as a sort of pyramid, standing on its tip. You’ve got this patient at the bottom, at the tip, with this extraordinary array of forces bearing down on them that could make them have conditions like diabetes. From the top you’ve got transportation policy, the plethora of shops selling fast food; you’ve got advertising. To expect me to make significant inroads on that individual at the bottom of that enormous pyramid – to blithely say something like, “You need to follow the Mediterranean diet, or move more” – that’s futile. There’s much bigger forces at work. So I do find it very frustrating. It’s almost to the point of nihilism: you can’t expect much traction from that one-to-one clinical encounter.’

  His colleague, Phil Kelly, presents a similar picture when asked if it can feel exhausting to encounter the same preventable conditions again and again: ‘That’s an interesting one. Because you’re right: because we have demonstrated, even within Europe, that we don’t have to have things the way they are. You can have a public health approach. It doesn’t have to be a totalitarian shove into the gymnasium.’ He pauses for a while: ‘But now I’m thinking – maybe I’m not worried enough. My job is to make sense of a certain group of things, and perhaps to keep doing it I have to see the glass as half full, or it would be very difficult to get through the hours until you’re next exposed to the difficulties of human existence. So undoubtedly I get frustrated, that’s a no-brainer.’

  The issues, Kelly notes, also reach into areas such as the wide inequalities of income and opportunity in the highly mixed southeast London district where he works. ‘I think we could have not monetised school playing fields over generations,’ he says. ‘We could have completely invested in other ways to transport ourselves around our cities. We could have normalised exercise in youth and teenage years, to make it extremely easy and normal to be engaged in some form of social exercise. It could be social contact as well. I think we have had the opportunity to do that. So do I get frustrated that we might have made different choices? Yes.

  ‘And if I think about the disparity in opportunity between people, I’ve no problem if by circumstance or luck or nous you have more of what society deems important, and you can send your children to places with magnificent sporting facilities. But is the net appropriately spread for the others? I don’t think it is. That frustrates me – why does the child in Peckham not have the same exposure to activity as every other child?’

  Such thoughts are not lost on politicians and senior policymakers, even if they are less likely to delve into such politically contentious areas. There is, nonetheless, an argument that health services could be doing more to raise awareness of the problems caused by inactivity. The NHS’s latest long-term strategic plan,24 unveiled at the start of 2019, contains fervent calls for more preventative public health action, but little in the way of specifics. In contrast, the whizz-bang world of high-tech, curative medicine is spelled out in much more detail, with promises of genomic screening, digital consultations with doctors and other innovations.

  In part, this is perhaps connected to the expectations of a public still more used to doctors handing out medicines to treat their ailments than offering advice on how to prevent them in the first place. Jonathan Valabhji says he believes this is gradually changing: ‘I’ve spent most of the last twenty-nine years sitting opposite patients in one setting or another, and one really tangible shift is that many people are now open to or even prefer the suggestion of a lifestyle intervention to do something, versus a tablet. Some people still have the attitude of problems being solved ideally on a prescription pad – that’s the model of the health service that many of our population hold dear. But if we tackle the younger and younger ages of onset of long-term conditions, and the costs to the NHS, we need to put a stronger spotlight on prevention. That’s very much the narrative.’

  During my day at King’s I spot something in common about the offices of Kelly and Whyte – both doctors have folded bicycles tucked away in a corner, their regular transport into work. ‘It might take me slightly longer, but it’s predictable,’ Whyte says. ‘There’s no stress about missing the train, or the train being late.’ He admits to being ‘quite militant’ about wanting peo
ple to be more active, advocating warning signs on lifts: ‘They would be like the ones on cigarette packets: “This lift will damage your health.” We’re on the fourth floor, and I see people getting in the lift and they go up one floor, sometimes even down.’ Whyte bursts into appalled laughter: ‘It’s terrible!’

  It is one thing for middle-class, well-educated doctors to know about the risks of sedentary living, but quite another for them to have the time to offer advice, and yet another thing in turn for patients to heed the guidance, and then continue to do so long-term in a world seemingly designed around inactivity.

  Some are looking for new ways to spread the message. Andrew Boyd, the lead on physical activity for the body that represents UK family doctors, the Royal College of General Practitioners, is pushing for a series of innovations. One would be for GPs to routinely work from standing desks, giving them a chance to explain the benefits to presumably surprised patients. Another would remove the ubiquitous electronic sign systems in surgery waiting rooms. Instead, doctors would walk from their office and call people in – giving the GP invaluable exertion, as well as a chance to discuss why they are doing it. ‘GPs can’t do everything – and in particular they can’t make it easier for people to walk or cycle places, or not have a desk job,’ Boyd tells me. ‘But too often people don’t even realise how dangerous their lifestyles are.’

  One recent change, Boyd says, is for time-pressed family doctors to be helped on these issues by specialist non-medical staff called ‘social prescribers’, who can spend longer with patients and help them find lifestyle interventions, whether based around activity or anything else, which could improve their health without the need for more medication. ‘There’s estimates that about a quarter of the people we see have non-medical issues, or at least an issue that could be managed with non-medical interventions,’ Boyd notes.