Learning from soft powerBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4645 (Published 01 September 2015) Cite this as: BMJ 2015;351:h4645
- 1Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111, USA
- 2Yale Law School, New Haven, CT
- 3The Fletcher School, Tufts University, Boston, MA
- Correspondence to: D Mozaffarian
The limitations of direct military intervention—“hard power”—for achieving foreign policy are increasingly highlighted by international events. Policy makers, military leaders, and intelligence experts now recognise the crucial role of preventive policy approaches—“soft power”—to tackle the multifaceted, upstream causes of conflict and instability.1 2 3 Soft power encompasses diplomacy, development, trade agreements, sanctions, foreign aid, and the promotion of education, women’s rights, and democracy. It prioritises prevention, the shaping of international affairs to pre-empt or minimise crises before they arise, and is supported by bipartisan commissions, independent agencies, and the military.4 Hard power is reserved as a last resort. Used early and efficiently, soft power not only provides effective and diverse policy options, but it costs far less and risks fewer lives.
These hard learnt lessons in national security provide eye opening parallels to a second, major industrial complex: the healthcare system. The modern approach to health emphasises “hard healing”—the reactive, individualised treatment of risk factors and diseases. Like the military, healthcare systems benefit from highly trained, dedicated personnel who use complex, advanced, and dizzyingly expensive technologies to achieve a proximal aim: treating a disease.
And they both primarily respond to, rather than prevent, major crises. This is expensive and inefficient. Just as military interventions may resolve acute crises but leave behind fragile or deteriorating circumstances, medical care may resolve acute health exacerbations but does not tackle root sociocultural, economic, and environmental determinants of chronic disease. Both systems also represent massive industrial complexes that incentivise self sustaining growth and high tech intervention rather than prevention. In many countries, these are the most costly systems: in the US, for example, annual military expenditures approach $700bn (£440bn; €610bn) and health system expenditures are $2900bn—together making up 23% of gross domestic product.
We propose the concept of “soft healing.” Like soft power, soft healing prioritises proactive prevention rather than reactive treatment and uses a range of strategies, not only the healthcare system, to promote wellbeing (box).5 Tools range from education and advocacy to economic incentives and multinational approaches. Examples of successful strategies include air and water regulatory standards to reduce contaminants and taxation and better and sanitation and surveillance systems to prevent infectious outbreaks.
Key tools for soft healing
Health education in public schools
National dietary and physical activity guidelines
Driver’s education programmes and licensing
Food nutrition and menu labelling
Warnings on tobacco, alcohol, toxic products (such as cleansers)
Promotion of seatbelts, bike helmets, sunscreen
Media and advocacy
Campaigns against smoking, drunk driving, drugs
Campaigns to increase healthy diets, activity
Environmental design and planning
Improved water and sanitation systems
Integrated home, work, school, and commercial land use; increased walkability and recreational spaces; improved traffic safety
Supermarkets and farmers’ markets near homes
School and worksite programmes
Comprehensive diet and physical activity programmes
Afterschool programmes and volunteer mentoring
On-site wellness programmes, fitness centres
Alcohol and tobacco taxes
Taxes on unhealthy foods, subsidies for healthy foods
Medical training, electronic health records, integrated clinical teams, quality benchmarks, and reimbursement structures that emphasise behaviour and lifestyle
Insurance premiums and deductibles for patients that foster healthier preventive behaviours
National surveillance for disease trends, outbreaks, major lifestyle, and population risk factors
Air and water quality standards
Food and restaurant standards and inspections to reduce foodborne illness
Standards for car and road safety, work safety, building construction
Car seatbelt, child seat, motorcycle helmet laws
Smoke free laws in schools, restaurants, worksites, public spaces
Marketing restrictions on tobacco and alcohol
Quality standards on food marketing to children
Health standards for nutrition assistance programmes
Child resistant packaging on drugs, other hazards
Fortification, such as folate in bread, fluoride in water
Limits on trans fat, sodium, sugars
Sodium reduction in packaged and restaurant foods
Government incentives for research and development to develop and promote healthier food products
Warning labels on toys to reduce injury
Agricultural policies to promote cultivation, transport, storage, and sales of healthier crops
Rigorous research on implementation, comparative effectiveness, and cost effectiveness of soft healing approaches
Public health leadership with oversight and budgetary powers to integrate soft healing activities
Coordinated soft healing approaches with bordering nations, close allies, trade partners
Participation in international strategies, such as the WHO Framework Convention on Tobacco Control, UN millennium development goals
Just as soft power operates outside the military system to minimise conflict, improve national security, and reduce the need for costly, extended military campaigns, soft healing strategies complement the healthcare system to reduce population risk, improve health, and minimise the need for inefficient, costly medical treatments. The healthcare system must also be used for soft healing, analogous to deploying the military for peacekeeping missions rather than full scale military intervention. Soft healing must be prioritised in the health system to encourage behavioural and lifestyle changes in the population. This might be achieved with integrated clinical teams, quality benchmarks, and reimbursement structures.6
Hard healing continues to dominate health policy and resources, despite the long history of advocacy for population health approaches by people such as Geoffrey Rose. Historical tradition, institutional incentives, and resource allocation are obstacles to balanced national approaches. In most nations, spending on public health and population research is dwarfed by healthcare, with billions of dollars being invested in precision medicine, drugs and medical devices, healthcare financing, incentive reform, and an ever expanding medical-industrial complex. These approaches can improve health but are often expensive, inefficient, and incremental. Meanwhile, soft healing approaches outside the healthcare system remain largely overlooked for tackling the pressing concerns of our time: diet, food systems, and lifestyle.5 Correcting these imbalances will require concerted, sustained efforts to reform strategic planning, re-allocate both money and personnel, and encourage private sector and multinational efforts. Moreover, better surveillance and communication systems are needed to inform decision makers.
We believe soft power provides a refreshing analogy for promoting the fundamental need for soft healing. Use of soft power enhances influence, promotes stability, reduces costly military interventions, and strengthens national security. Similarly, more soft healing will improve health, reduce costs, and enable government and corporate resources to be used for other crucial strategic investments. At the same time as seeking more individualised, precision medicine, we must also add robust, community facing, population medicine. Both health and economic considerations support this evolution. The broad national benefits should command strong support from the public and multiple political parties. A shift in focus towards soft strategies will create “smart” healing—a thoughtful, coordinated, and highly effective blend of both soft and hard tactics. The complex, multifaceted health challenges of the 21st century require a shift toward multicomponent soft approaches that use all appropriate tools to safeguard our health.
Cite this as: BMJ 2015;351:h4645
Competing interests: We have read and understood BMJ policy on declaration of interests and have no competing interests to declare.
Provenance and peer review: Not commissioned; externally peer reviewed.