I passed a church some time ago and saw a sign that said "WORRY IS THE THIEF OF JOY". It got me thinking, in the middle of this harried and frustrating week, about how worry is often the thief of health. There are too many ways to be unwell; spiritually, psychologically, socially and of course, medically.
My cousin, who happens to be a priest, looks after people's spiritual health. One day we were talking about what our days were like. It slowly dawned on both of us; in a lot of ways we do the same thing. Hey, I do primary care, so I 'm not in the OR using technology. When faithful people are in distress, they may go to their clergy for advice and guidance. The conversation is often enough for them to feel better. Others prefer to lock themselves in their room and contemplate for a few hours and then be able to move on. They can function better, interact with people with less friction, and generally 'be' better.
Patients who come to the clinic also feel unwell. It seems that as medicine becomes a corporate machine, there is a growing expectation of cut-and dry diagnosis, investigation and treatment. There is an expectation of a health outcome as a product that can be pre-packaged and mass produced. I suppose that may be a reasonable expectation for some disease states, as far as we are able to understand them. If you have a problem with a heart valve, there is a cut-and-dry surgical method to repair it.
But what about the fact that a significant proportion of visits to doctors do not yield a firm diagnosis. In short, half the visits to primary care offices are for vague non-specific symptoms. There is no organic pathology.
Health has many definitions. The scientific approach to medicine which emerged to dominance in the 20th century tends to focus on health as an "absence of disease". It sounds like a reasonable definition, but there are too many who are unwell, know they are sick in some way but no disease entity can explain their condition. People have headaches all the time, but they don't have a tumor, an aneurysm or even migraines.
The alternate definition is the one from the World Health Organization that states: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” It is so broad that the medical world doesn't really know what to do with it. This definition is most appropriate for public health and policy makers.
It is a political definition of health. If you use it, then the people who ensure clean water and good sanitation in your community are rightly thought of as health workers. Without sanitation workers, thousands would die of stool-transmitted bowel infections, just as in many 3rd world countries today. By this broad definition of health, keeping people well requires many things unrelated to doctors or the things health-care workers do.
At its most basic, a healthy life requires a secure food source and reliable shelter from the elements. If this seems trite, just try to imagine not having either. Most of us take food and shelter for granted. This is a testament to the effectiveness of our society that it can provide these as well as it does.Make no mistake, the standard of level achievable by the American middle class is the great success of this country.
Sanitation and clean water go hand in hand.
A good job with a satisfying purpose and a steady source of revenue are also very important.
Our connections to people, individual relationships and a sense of belonging to a community are also important parts of feeling good. Where else will we find support when we are stressed and twisted out of shape by the world at large? Nothing gives a human being a sense of purpose as much as family. This applies for most families, despite our minor pathologies and dysfunctions.
Literacy is also critical to well-being; no one gets a great job without knowing to read and write. Moreover, if you can't read the instructions or your pill vial, you're out of luck. Sanitation, literacy, employment, quality shelter and secure food and water are not often considered to be in the purview of medicine as it has been conceived in the last century. This is the world of public health and health policy and it has huge impact in the world of primary care. In the absence of the essentials, where do you think people will go. Usually an internist or pediatrician for diarrhea, work-related back pain, depression, weight problems...
If you were running a community health center, I bet you'd be pretty hard pressed to convince the local County Council to emphasize housing and education as a HEALTH priority! There are no funding streams available for physicians and nurses who want to improve the social well-being of their patients.
When health is redefined as well-being, we recognize that government plays a role in many aspects of our lives. Government apparently has a role in making our lives better. It works to make sure we are secure from foreign threat and ravaging hordes of Vikings threatening to burn our homes. The government provides a framework by which we can purchase homes or otherwise obtain shelter, either though mortgage assistance or emergency shelter in the case of disaster. In addition the rule of law, enforced by the government, secures our property. A regulatory backdrop allows us to have better functioning markets and a transportation infrastructure exists to drive our economic success and helps us secure jobs through this activity. We get together in other ways as well, building sewers, schools and other infrastructural elements that improves our lot collectively.
When it comes to health care, we have trouble seeing it as an infrastructural building block of a nation. At least half of health outcomes are the result of individual choices and the health of one's neighbor is not generally recognized as something which improves one's own life.
Once we have gotten past the major infrastructural domains that have an impact on health, the following interventions have been shown to have the most significant effect on health. These are pretty basic items, but we usually recognize them as health-related. Programs to address these issues are usually funded through public health departments.
- One of the most basic tenets in staying healthy is: do not smoke. That alone saves more lives than all the rest of medicine’s contributions.
- Wear a seat-belt and don't drink and drive. Every year nearly as many Americans are killed on the roads than died in the entire Viet Nam war.
- Physical activity and recreation are important. Staying socially active is critical, but then again so is keeping physically active. Most of our jobs do not give us the opportunity to move our bodies as they did in the days of manual labor. It was back-breaking work and caused a lot of problems due to overuse. Now we find that the opposite – sitting in an office for twelve hours a day – is no less destructive. We need to use our spare time doing something physical, such as swimming, walking, or going to the gym.
- A balanced diet is important to keep vitamins and nutrients up, also to avoid too much fat, carbs and the risk of obesity.
- Many diseases are preventable by vaccine and these need to be kept up. Good prenatal care and care for small children carry a huge bang for the effort.
"Bang for the buck" is a method by which government one can be held accountable for health care expenditures. But it is more difficult to measure well-being than health status in narrow terms. Data is more important than determining the validity of the measure.
It is easier to measure the rates of antibiotic administration that to tell if that really makes a difference in the scheme of things. We have to drive, so we won't look at accident mortality as a measure of health. We decide that we have the best health care system in the world because you can swallow a pill and get screened for cancer, but we won't worry that 99.9% of the population has no access to expensive new technological interventions. We won't worry about the social and spiritual well-being of our neighbors, since they made bad choices for which we are not responsible.
Instead we will worry about our accumulation of material things and getting through our to-do list, avoiding people less well-off and becoming more socially isolated ourselves to the point that we cannot recognize that there are poor people amongst us. We will worry about maintaining our status and worry about our assets and worry about getting mugged and bridges collapsing and the ding on the passenger side of the SUV and the price of of gas and getting a promotion and getting to the PTA on time and renewing the tags on the car and stopping at the supermarket and taking the kids to ballet and softball and...
We don't have time for a 30 minute walk. We don't have space in our crowded lives to contemplate or just to be present for half an hour. We don't even have time to listen to our neighbors for all the criticizing of their poor choices. There is no well-being, there is no joy. And we think we're healthy?