Environments for Health

John J Macdonald, University of Western Sydney, Australia

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136566370
• Edition: 1
• Topic: Medicina
• Subtopic: Salud pública, administración y atención

'John Macdonald once again turns the traditional approach to health care on its head. Instead of merely diagnosing and managing disease, he urges health services and indeed society to foster health... and articulates a vision of a health promoting a salutogenic society'.
Dimity Pond, School of Medical Practice and Population Health, University of Newcastle, Australia

The vast proportion of cash spent on health care by governments and individuals in the world is spent on systems that are based on a more or less Westernized acute care model. The imbalance of these systems, with their overemphasis on cure, as opposed to care and prevention or maintenance of health, is well documented. Salutogenic health care takes a holistic view of the individual as part of a social and environmental continuum rather than as an isolated packet of symptoms, and seeks to reassess the very meaning of health. There are some indications that we, as a global culture, are moving towards this new salutogenic model, but the speed of the movement has to be accelerated. This book sets out to chart the main steps of this movement and to indicate some of the ways of thinking and action which can help form new ways of approaching health care.

1

STILL IN THE BUSINESS OF FIXING UP

We medical men are wayside repairers of the human machines which break down on the road of life.

Sir A. Keith, The Engines of the Human Body

Mammy … she used tae always go tae auld Doctor McKillop, who’s aboot ninety-three and gies ye Sudofed tablets whether you’ve a broken leg or a broken hert.

Anne Donovan, Buddha Da

One of the major tasks of the postgraduate training of doctors and nurses is to re-humanise the practice of medicine.

Professor Rita Giacaman, Birzeit University, Palestine

THE MEDICAL MODEL: AN ENDURING IMBALANCED VISION AND PRACTICE

Depending on one’s point of view, western medicine is either at a peak of great achievement or going through a time of serious crisis. Either way, the key is technology and the role one attributes to it. On the one hand, there have been vast developments in the area of medical technology, which have led, among other things, to the development of genetic medicine, with the promise held out of eliminating all disease. This can be seen as incredible progress, the human mind reaching out to fend off menacing influences of disease and to enhance our lives and health as never before imaginable. Others would see that this emphasis on biological manipulation is part of a fundamental and ever deepening illusion, and that a dependence on scientific technology will never ‘cure the world’s ills’. The most striking example is perhaps that given by the HIV/AIDS epidemic, claiming some 3 million lives in 2002 alone (UNAIDS, 2002). Technology alone was never going to ‘solve’ the problems associated with the management of this condition and the healing of the individuals and communities afflicted by it. The vast amounts of money spent on this approach (looking to technical solutions) to the neglect of the care of those families affected by the epidemic is a striking example of how distorted our thinking and policies can get by pursuing the notion of technical solutions to human problems.

There are those who see the current crisis of medicine as one of funding: there never seems to be enough money to meet everyone’s ‘health’ needs, even in the most advanced economies. It is not difficult to persuade the general public that more money for some new medical technology or for more hospital beds is an ‘urgent necessity’. In some countries, the road to election time is scattered with promises of new hospitals, or at least new hospital beds. Health professionals and others working on behalf of a better distribution of health resources in support of health initiatives in the community are wary of imminent elections since these can tempt politicians to promise more technical medicine (buildings, beds, machines) and the personnel to staff them, almost inevitably taking money away from the less glamorous work of sustaining health in the community. The assumption here is that we have got it right really, this business of health – we have the right road map, all that is needed is to throw more money at it.

Others would see health systems undergoing a crisis of credibility. People are losing faith in health systems. To be fair, this is sometimes due to unrealistic expectations: in a world in which there is an implicit assumption of the possibility of perfect health, by which is meant the total absence of disease, discontent is inbuilt. The inevitability of some forms of suffering – and death itself – is something often absent from public consciousness in modern global culture.

Large amounts of gross national product (GNP) are spent on health systems: US 13.6 per cent, UK 8.2 per cent, Australia 9.8 per cent (Brown, 2004; National Health Debate and Poll, 2004). Despite this considerable spending, many people are discontent with health services. There is the embarrassment of iatrogenesis and hospital associated illness (HAI): conditions which people didn’t have when they went into care, but picked up during their stay in the institution or other contact with the health care system. It is often only the necessity of publishing plans to reduce the number of these conditions that has given this phenomenon some publicity in recent years. There is increasing documentation of the rise in the extent of drug-resistant conditions, often due to an over-prescription of antibiotics. Solutions based on technology seem to be failing.

DISCONTENT: PEOPLE VOTING WITH THEIR FEET, ‘COMPLEMENTARY MEDICINE’

In many industrialized countries, people are seeking help from ‘alternative’ or ‘complementary’ therapies. This last nomenclature is often an inaccurate description of the relationship between systems, since in many cases both ‘allopathic’ and ‘alternative’ therapists do not see one another as ‘complementing’ the skills and insights of the other, but rather as the holders of different views, competitors both in terms of ideas and for patients’ loyalty and payments. The uptake in western societies of the services of naturopaths, homeopaths, spiritual healers and other non-conventional practitioners is a clear indication of population dissatisfaction with conventional health care and of the need for a major rethink for conventional, ‘allopathic’ health services. People are voting with their feet and, importantly, with their purses and wallets. Talking of this situation, Ernst has this to say:

In essence, therefore, no single determinant of the present popularity of complementary and alternative medicine exists, but there is a broad range of interacting positive and negative motivations. Some of these amount to a biting criticism of our modern healthcare system. Regardless of whether this criticism is valid or not, it is often deeply felt by those who turn towards complementary and alternative medicine, and mainstream medicine would be well advised to consider it seriously.

Ernst (2000), p1133

In a broad global perspective, colonization by western countries has involved a process of cultural colonization or imperialism, whereby colonized people have often come to see themselves and their culture, including their healing systems, through the eyes of the colonizers (Fanon, 1968). The result has been a massive underdevelopment of traditional medicines and the wholehearted adoption by many of the values and approach of western medicine. The great irony here is that in the west, the discontent with allopathic medicine to which we have referred has grown and brought about, in the west itself, not only a keen interest in but wide-scale practice of non-western medicines, as well as extensive growth of ‘alternative’ or ‘complementary’ therapies. Perhaps the most striking example lies with Chinese traditional medicine; in particular, the practice of acupuncture. Twenty years ago this practice was widely described in the west as dangerous nonsense. Now it is not only widely accepted, with westerners seeking out Chinese practitioners, but many western doctors are following courses in acupuncture techniques. This is extremely interesting from the point of view of philosophy, notably the philosophy of science, since western medicine cannot justify acupuncture within the limits of its own parameters. The ‘meridians’ or mediators of the energy flows, which explain the practice of acupuncture and acupressure, are not susceptible to scientific observation as western science knows it. The practice is established, often ‘justified’ in western scientific terms, but in fact represents a real challenge to the parameters of thought of western medical science. The real irony, of course, lies in the phenomenon of ‘developing’ countries, having been brainwashed to reject traditional healing systems as backward and unscientific, now witnessing not only the adoption of many of these practices by western societies, but even endorsement by international agencies. The very processes of global colonization that undermined traditional medicine in the first place will now endorse its reintroduction into developing countries, of course modified and commercialized even more than it was in the past.

DISTINGUISHING THE BABY FROM THE BATH WATER

The baby

There can be no denying the great achievements of western medicine and the progress it has made in terms of recognizing and dealing with some major human conditions of disease. Those of us who have criticized the ‘medical model’ must nevertheless (humbly) acknowledge all the genuine alleviation of human suffering that has been achieved through certain practices of western health systems; in the context of older people’s health it has been pointed out that:

The power of medical care to improve the quality of life should not be disregarded. Surgery for things such as hernias, cataracts, prostate, varicose veins and hip joints may not be glamorous or do very much to improve life expectancy, but they are important to the quality of life of old people.

Blane et al (1995), p11

And in a wider global perspective, the WHO is right to remind us of the considerable achievements involved in the eradication of smallpox and the reduced risk to millions of people of infectious diseases such as yellow fever, poliomyelitis, measles and diphtheria (WHO, 2002a).

The bath water

Such achievements notwithstanding, the western model of health care is, at the very least, straining within the expectations put upon it, or that it puts upon itself. What it seems to lack, despite the lessons that are there to be learned about its limitations, is humility. The assumption seems to be that only time and money are needed to ensure that in the development of technologies we will find all the answers to the health issues of the world. Medicine will conquer all. This optimism, however, has created a tension within western popular culture and within the profession itself. Sickness and disease seem as much part of individual and collective life as ever. People still fall sick, age and die. Doctors are understandably frustrated by the expectations of cure put upon them by society; many people in western societies having been brought up to turn to the medical profession when healing of any sort is required. The role of the doctor as priest and spiritual comforter in a secular society is readily observable, a reality not necessarily pursued by the medical profession but one thrust upon them by a needy population (Bauer, 2001).

BEYOND MEDICINE

Not all conditions of illness can be cured, and certainly not all from within the repertoire of the healing tools available to the average doctor, nurse or hospital. Much of the causes of disease lie outside the control of the health profession, as do, likewise, much of the well-springs of health and healing. They lie, in general terms, in the context of people’s lives. The idea of the importance of context, environment or life circumstances has long been recognized in public health in, for example, the use of the analogy of ‘upstream’, ‘downstream’. Some doctors, nurses and other health workers realize that they are often busy with the symptoms of problems. As a result, they are frequently dealing with ‘downstream’: populations, people who have fallen into the ‘river of illness’, while being conscious that ‘upstream’ – in the wider social context of people’s lives – lie the causes of much illness, whether in the personal, social or economic domain. The idea of ‘specific aetiology’ of disease (one sickness with one cause, the latter to be identified and eliminated) is generally seen as so simplistic as to be of no account (Macdonald, 2000) even if this approach still influences some medical practice.

THE NEED FOR NEW VISION

The emphasis on technical competence to deal with pathologies, often within institutions of expensive treatment, almost always takes precedence over any attempt to argue for a broader view and vision involving a community-based focus and community-based mechanisms, which deal with local issues and working links and access to systems ‘higher up’. The need for such mechanisms and such an approach is increasingly being felt in both developing and developed countries:

Across a whole continent – Africa – our age is witness to the tragedy of an epidemic of unimaginable proportions. At the end of 2002 there were 42 million people living with HIV/AIDS, of whom 29.4 million in sub-Saharan Africa.

UNAIDS (2002)

The disappearance of a whole generation, those we can describe in economic terms as ‘productive’: men and women aged 18–45, has meant that top-down health services, often hospital based, even with the best will in the world, are left standing impotent in the face of the health needs not only of patients but, just as tragically, their children and the older generation left to care for them. Similar tragic scenarios are emerging in other continents. It is not simply that health systems have not been able to cope, it is rather that the health systems, following a globalized notion of health care, using whatever finances they have mainly on hospitals and acute care – by and large for those who can afford these – have been shown to be imbalanced and flawed in their basic assumptions and approach. Where logic would call for great effort at prevention and early intervention as community based as possible, the structures (and often mentalities) in place are focused on disease in hospitals.

The same imbalance shows as much in so-called developed countries where we have the phenomenon of an ageing population and a health system often geared to acute rather than chronic care, often missing the needs of this population in a serious way.

Today, one of every 10 persons is 60 years old or over, totalling 629 million people worldwide. By 2050, the United Nations projects that one of every five persons will be 60 or older, and that by 2150 this ratio will be one of every three persons. By 2050, the actual number of people over the age of 60 is projected to be almost 2 billion, at which point the population of older persons will outnumber children (0–14 years).

United Nations (2002), Article 2

Being old is not an illness, nor does it necessarily involve illness. But there is no doubt that many older people, one may say, naturally experience some form of chronic illness as life progresses. The management of this situation in an efficient and humane way is an enormous challenge for society at large and health services in particular. Again we see the serious flaws in a system focusing largely on acute care: a hospital-based system which, given the high cost of modern technology and health professionals, consumes the greatest proportion of the health budget to the detriment of many older people who are in need of another approach to care that is less institution based and addresses their needs for treatment and maintenance of health where they live or as close to it as possible. Of course, ageing is also a phenomenon challenging health systems worldwide and not just in developed countries, as is witnessed by the recent WHO initiative of an integrated response to ‘rapid population ageing’ (WHO, undated, Ageing and Life Course Program).

Health systems in poorer countries with hospitals overflowing with children who are suffering from preventable illnesses or dying from conditions for which their families cannot afford treatment or which are amenable to community-based solutions if identified early, are facing an imbalance similar to that in the health systems of ‘richer’ countries with hospitals containing large cohorts of elderly patients suffering from chronic conditions, often with a ‘psychosomatic’ dimension, who could be cared for outside the hospital and often in their own homes. The problem is basically the same in both situations: we are using the wrong tools for the job, investing in a lopsided ‘health’ system: medicine has ‘its place’ in the rational planning of the provision of care, but expecting medicine to ‘create’ and maintain health and prevent disease is clearly asking too much of it. Hospital-based systems cannot provide the panacea many still expect them to. But we will not creatively expand and develop our health systems unless there is a popular and professional development of thinking around health and health systems. We need another way to think health and do health care.

HEALTH OUT OF CONTEXT

The above scenario of mismatch between ‘problem’ and ‘solution’, whether in the paediatric or HIV/AIDS wards of the developing world or the general or geriatric wards of hospitals in industrialized countries, encapsulates an important dimension of the crisis of modern medicine: an individual doctor or nurse faced with a collection of individual patients. The ‘causes’ of the conditions presented by the patients often lie, at least partially, in the social, economic, cultural and personal emotional and spiritual context or environment of the patients. On discharge, the patients will return to their living environment, which will either foster or hinder their healing, help to maintain them in health or precipitate them ...

Table of contents

• COVER
• HALFTITLE
• TITLE
• COPYRIGHT
• CONTENTS
• ACKNOWLEDGEMENTS
• LIST OF ACRONYMS AND ABBREVIATIONS
• INTRODUCTION
• 1 STILL IN THE BUSINESS OF FIXING UP
• 2 STEPPING AWAY FROM THE MEDICAL MODEL: THE IMPORTANCE OF CONTEXT
• 3 THE SOCIAL DETERMINANTS OF HEALTH
• 4 LEARNING FROM OTHER CULTURES: HEALTH AS THE FIT BETWEEN THE PERSON AND THEIR ENVIRONMENT
• 5 RECONCEPTUALIZING HEALTH
• 6 AN EXAMPLE – THE HEALTH OF MEN: A SALUTOGENIC APPROACH
• 7 CONCLUSION
• REFERENCES
• Index