On ageing, economization of health, and media ethics: how much is a month of life worth?

INTRODUCTION

On 19.04.2018 the Polish daily Gazeta Wyborcza published an article written by Leszek Kostrzewski which informed the readers that in 2017 the average life expectancy of Poles over 60 years of age dropped by a month compared to last year [1]. The author, however, attempted to reassure his audience already in the lead of the article; “despite appearances, this is actually good news for Poles who are going to retire this year”. Another daily, dziennik.pl appeared even more jubilant about the falling life expectancy, publishing an article entitled “We live shorter! And... it does not have to be bad news” (Fig. 1) [2]. What positive aspect of premature mortality of the elderly have the journalists uncovered? Well, seniors may well be living shorter lives, but in return their retirement pensions will go up. People who have collected 300,000 PLN (circa 80,000 USD) of retirement capital will have a pension increase of PLN 4/month (circa 1 USD) for women and PLN 11/month for men (circa 3 USD). Why should the elderly worry about having one less month to live, seemed to say the journalists, after all their lavish extra pension money will buy them a bread roll and some milk, and they may even be left with some spare change.
The articles mentioned above are only a symptom of a wider phenomenon in Polish public discourse. The fact that Polish mass media are melting serious problems of public health into the bush of dubious economic benefits is nothing new. Recent examples are easy to find. In April 2018, the daily Rzeczpospolita devoted its first page to the proposal prepared by the Ministry of Health to ban beer advertising on TV [3]. The newspaper neglected to mention that Poland is one of the few countries where the consumption of alcohol is increasing, the average citizen consumes almost 10 liters of pure alcohol a year, and premature deaths caused by drinking alcohol continue to grow [4]. Instead, the author of the article, Aleksandra Ptak, expressed her concern about how the ban will affect the advertising funds of television channels (it’s worth pointing out that in many European countries, including France, the Scandinavian states, and even Russia, such bans are already in place and television channels are doing rather well) [5]. The Polish press also presented a similar approach when describing issues related to cigarette smoking. When the European Union in 2016 decided to prohibit the sale of flavoured cigarettes in its Tobacco Products Directive, the Polish media largely did not report on the 70,000 by tobacco-related premature deaths in Poland, or how the new law could constitute a chance for the million smokers of flavoured and menthol cigarettes in Poland to quit. Instead, the daily Gazeta Prawna decided to frame the TPD provisions as “an EU hit against Polish tobacco farmers” [6].

HEALTH, ECONOMICS, AND MEDIA ETHICS

Researchers from the London School of Hygiene and Tropical Medicine in a recently published study characterised the public debate on health policy in Poland as dominated by economic issues and marginalising the health of Poles and the voices of authorities in the field of public health [7]. The phenomenon of ‘economizing’ many domains of social policy is characteristic of numerous liberal democracies, but it takes on different forms and sizes in different countries. In Poland, there is an exceptionally strong trend that leads to the takeover of the debate about public and social issues by economic considerations. In this context categories such as “interest”, “profits”, and “losses” become the most important arguments applied to justify political decisions [8]. Purely economic calculation of what will be profitable and what will incur losses to the state budget is accompanied by the assumption that individual profit is more important than the well being of the society (and its proxies such as public health). This logic leads to a situation in which all manifestations of social solidarity and concern for citizens as a group are treated as an attack on the freedom of individual economic activities and a threat to private interests. The assumption behind this is the underlying antagonism between the common good and the individual good. In the Polish context, this premise is founded on a very simple semantic operation consisting of associating everything that is connected with “community” with the “communism” of the Polish People’s republic, while at the same time attributing positive connotations to opposite concepts (for example: collectivism vs. individualism). The above mechanisms and paradigm shifts are also present in the debate about health. The “economization” of public debate becomes extremely dangerous when it begins to touch upon health issues. This is particularly evident in the media discourse, where it is often accompanied by superficial, not to say unreliable, analyses. Attempts to attribute monetary value to health interventions (“putting a price tag on life”) inevitably lead to the opposition of economic and public health interests. Unfortunately, in this confrontation, health is in a lost position. People are an “added value” for the economy only when they are in so-called productive age. In most countries, somewhere in their mid-60s, a statistical citizen becomes an economic „burden’ on the state budget. The renowned British epidemiologist Sir Richard Peto described it vividly during one of his lectures: “The best thing we could do for the economy is to go out on the street with a machine gun and shoot every person who looks like their approaching retirement age. Our obsession with putting a price tag on human life can lead to such a conclusion”1. In the logic of public health economics, the role of the machine gun is played by diseases of the old age, especially those related to alcohol and tobacco consumption. These addictions not only contribute to the state budget in the form of excise taxation, but also in cutting short the lives of the elderly – and every month during which they do not need to be supported by the state can be converted into monetary value. It is this approach that leads to ethically doubtful statements in Polish newspapers, such as Kostrzewski’s assertion that “All Poles who are going to retire this year will benefit from lowering the average life expectancy” [1].
What is most striking in the treatment of public health issues by the Polish media is their attempts to bring down the significance of human life to its economic worth. The value of life has traditionally been treated as impossible to translate into monetary terms, transcending economic categories. Is the „social consensus’ on the division of values into economic and non-economic (e.g. ethical, moral, religious, etc.) collapsing before our eyes?

THE PLACE OF PUBLIC HEALTH IN POLISH MEDIA

It is necessary to praise Gazeta Wyborcza for one thing. It has probably been the only significant daily newspaper to devote significant attention to the decline in the life expectancy of the elderly in Poland. For comparison, when last year news broke about the decreasing life expectancy in the United States [9], as well as in Great Britain [10], this caused a media storm. The US and British media called their politicians on the carpet, and explored potential solutions for how to deal with the public health crisis (the US press pointed to the epidemic of opiate abuse, and the British press to the effects of the Tory government’s austerity policy). In contrast to the Polish press, the western journalists were not interested in whether the premature deaths would help lift pensions by a handful of pounds or dollars.
The problem outlined in this article cannot be resolved by simply changing a TV channel, or picking up a different newspaper on the way to work. The media in its totality have an unquestionable influence on the public debate, on what and how is framed as a significant social problem in the eyes of both citizens and policymakers. The sociologist Marek Czyżewski (and colleagues) calls public actors who have such a towering influence on the shape of a public debate “symbolic elites”. This concept does not refer to the axiologically understood “elitism”, but rather to the significance that their words have for giving prominence to, and solving, particular social problems [11]. What appears in the media is not – or at least should not be – guided by viewership ratings, but should rather come with an acknowledgment of their ability to shape the public perception of social, political, economic, and health problems. That is why, if the media want to be socially responsible, their messages should be driven by honesty and accountability to their audience.
The faltering of the increase in life expectancy in Poland is all the more worrying given that the gap in health outcomes between Poland and Western countries still persists [12]. In Italy, a country in the midst of an economic crisis, life expectancy is five years longer than in Poland (at over 83 years) [13]. Poland in the last decades has undergone an unprecedented period of increasing life expectancy, principally thanks to the improvement of disease prevention and prophylaxis (especially the spectacular decline in smoking prevalence and the improvements in dietary habits). The reversal of this trend, which we are starting to observe in the oldest age groups, should therefore be a serious warning signal for Polish society and politicians. Unfortunately, apart from the increasing tendency to blame air pollution for all of the social ailments, the Polish media did not attempt to launch a serious debate on why Poles still do not live as long as the inhabitants of other western countries.

HEALTH IN ALL POLICIES

Since the end of 20th century the Human Development Index (HDI) has been becoming an increasingly prominent measure of the socio-economic development within countries. The constituents of the HDI are life expectancy at birth, mean of years of schooling for adults aged 25 years and more and expected years of schooling for children of school-entering age, and gross national income per capita. Those elements measure three basic dimensions of civilizational development: a long and healthy life, being knowledgeable, and having a decent standard of life [14]. The HDI provides a good illustration for why life expectancy should be perceived as a key measure of country development in general, and not just of the performance of its healthcare system. Poland is currently placed 36th among highly developed countries in the HDI, leaving much room for improvement. How can this be achieved? Of course key factor here are political decisions helping to shape an environment in which citizens have an easy access to treatment, but even more importantly to healthy lifestyles and prophylaxis.
At the core of the health situation in every country lies the comprehensive approach of state authorities to questions of health policy. Politics is not merely composed of laws and regulations, but also of the different ways of implementing them (or not), as well as defining what is included in the realm of interest and activity of the authorities. In 2006, during its presidency of the European Union, Finland proposed the notion of health in all policies (HiAP) [15]. The former director of the Polish Institute of Public Health, Cezary Włodarczyk, characterized HiAP as a postulate that all political entities whose actions may lead to health consequences take the responsibility for them [16]. As health is a key factor underpinning the quality of life of citizens, it should be considered as central in all areas of broadly understood social policy of any country.
Factors affecting public health – including the health literacy of citizens, access to healthy food and environment, physical activity, a well-functioning system of healthcare and prevention, etc. – are complex and cannot be regarded as the sole responsibility of one government department. In other words, the health of citizens is not dependent solely on the actions of the Ministry of Health. The activities undertaken by many different ministries shaping, among others, educational politics, housing, communication, agriculture, public security and, first and foremost, economic issues, are as important for public health. Under the HIAP approach, the health of citizens is not deemed important only in its relation to economic outcomes. Rather, an opposite approach is taken, and it is within economic policy that the means for improving healthcare and population health are sought. Certain countries, including the Scandinavian states, have taken this path. Instead of “economizing” public health, they are offering a system in which economic policy is becoming subordinate to public health considerations.
The media must face up to their responsibilities. They play a key role in shaping the attitudes of society. They can also influence policymakers. We hope that a time will come when the Polish media will acknowledge that public health is a matter of priority, and help build the functional health competencies of Poles. If this is not done, in a few years we will wake up to a society desperately unprepared for the future – ageing, ill, and lacking the basic tools of health literacy.

DISCLOSURE

The authors report no conflict of interest.

References

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AUTHORS’ CONTRIBUTIONS

MZ prepared the first short draft of the article, IM prepared the extended version of the article. All authors contributed to preparing the final version of the text.