Intended for healthcare professionals

Observations Reality Check

Power to the people

BMJ 2011; 342 doi: (Published 06 April 2011) Cite this as: BMJ 2011;342:d2002
  1. Ray Moynihan, author, journalist, and conjoint lecturer, University of Newcastle, Australia
  1. Ray.Moynihan{at}

Could a new and informed citizens’ movement make medicine healthier?

Three decades after John Lennon’s death, his ghost made a surprise appearance last month on a most unlikely stage. “Power to the people,” proclaimed Gavin Mooney—citing a line from the late Beatle—from the podium of a conference on rural health in faraway Australia. Until recently professor of health economics at Curtin University, Perth, Mooney was outlining a vision of an informed citizenry making health systems accountable to the communities they are supposed to serve. “Now wouldn’t that be a revolution,” he concluded, to hearty applause.

As healthcare eats an ever bigger slice of public spending everywhere, calls are growing for the public to take more of an interest in how their money is used. John Menadue, from the Centre for Policy Development in Sydney, told the same conference in March that it’s time that an educated and informed community challenged the power of vested interests in medicine, notably doctors’ associations, private health insurers, and drug companies. Formerly an ambassador to Japan, a manager within Rupert Murdoch’s empire, a chief executive of Qantas, and at one time the top public servant in the nation, Menadue, like many others, is disturbed by the misallocation of so many resources to clinical medicine at the expense of genuine prevention and work on inequity and the social determinants of health.

A concern that too much medicine may actually be harming people is also behind the push for more active engagement of citizens in healthcare decision making. “We’re poisoning our old,” declared the University of South Australia professor of public health, Robyn McDermott, from the same podium, citing the large numbers of our parents and grandparents admitted to hospital with side effects of treatments. “We’re prescribing too many pills for older people for conditions for which they could be much better served by other treatments,” she said. Her presentation highlighted how diet or lifestyle change can reduce a person’s risk of disease for a fraction of the cost of new drugs, and she emphasised the effectiveness of strategies such as reforming tobacco laws in cutting heart disease. “We’re medicalising problems that we can much more effectively deal with with legislation, regulation, and community level activity,” she said, echoing calls for more “citizen involvement.”

In contrast to the word “consumer,” “citizen” carries a deeper democratic resonance, hinting at reciprocal responsibilities between the people and the state. Much of the non-professional voice in medicine in recent years has come from consumer type groups, often advocating for greater attention to their specific disease and celebrating the latest treatments. For obvious reasons powerful vested interests sponsor these patient groups, and it is estimated that perhaps two thirds of all health charities receive funds from drug or device manufacturers. Sometimes sponsorship is negligible; on other occasions the association seems to be little more than “astroturfing”—the practice whereby corporations use fake grassroots organisations to promote their interests. A few years back a star studded outfit called the Boomer Coalition was urging the US public to constantly test their lipid concentrations as one way to fight heart disease. One of the two founding partners of the coalition was Pfizer, the manufacturer of a top selling lipid lowering drug, which had invested millions of dollars in the new group, the Wall Street Journal reported.

The confluence of interest between advocacy groups, those who sell treatments, and those who prescribe them makes for a potent cocktail of influence, almost always pushing policy makers in one direction: more tests, more procedures, more beds, more pills. Few groups take a bird’s eye view, which would make it painfully clear that overdiagnosis and iatrogenic harm are an increasingly serious threat to human health and the rational use of public resources.

As someone reporting in this field for more than a decade, I sense that what’s often missing from the debate is a voice genuinely representing the public interest. Sponsored advocacy groups are quick to celebrate a new treatment or technology but slow to publicly criticise its limited effectiveness, excessive cost, or downright danger. And, like many journalists, politicians tend to be unnecessarily intimidated by senior health professionals and passionate advocates, who too often lend their credibility to marketing campaigns that widen disease definitions and promote the most expensive solutions.

The emergence of new citizens’ lobbies within healthcare, well versed in the way scientific evidence can be used and misused, may produce a more informed debate about spending priorities. Such citizens’ groups could routinely expose misleading marketing in the media and offer the public and policy makers realistic and sophisticated assessments of the risks, benefits, and costs of a much broader range of health strategies. Frightening figures—like the recent estimates of radiation risks from overused computed tomography scans (BMJ 2011;342:d947, doi:10.1136/bmj.d947) —would not fall straight from public consciousness but would feature in ongoing campaigns to make healthcare safer and fairer.

Gavin Mooney says that using “citizens’ juries” is another way to seek untainted public input into policy making. Randomly selected from electoral rolls, these small groups of around 15 citizens are given the information and the time to deliberate collectively on important questions of health funding, and Mooney says that in his experience with this experiment they invariably argue for more equity rather than for a crude rise in numbers of local hospital beds.

“People care,” Mooney says. His desire for more citizen engagement in health debates is part of a wider aim, he says, of enhancing democratic participation and rebuilding a lost sense of community. You may say he’s a dreamer, but he’s not the only one.


Cite this as: BMJ 2011;342:d2002


  • Editorial: Supporting patients to make the best decisions (BMJ 2011;342:d2117, doi:10.1136/bmj.d2117); Feature: Welcome to the century of the patient (2011;342:d2057, doi:10.1136/bmj.d2057).