Healthcare today is deeply flawed despite the incredible advances in medical technology that have undoubtedly saved millions of lives and helped many others overcome catastrophic and/or crippling illness. Nevertheless, the seduction of technology and a proliferation of narrow specialties in medical care have also created an overly medicalized, fragmented, depersonalized, and transactional approach to healthcare. Indeed, the current medical practice of healthcare ranges from a patronizing benefactor (provider)-beneficiary (client) relationship to one where “care” is an overtly mercenary service/commodity accessible only to the wealthy.
So why is the medical industry afflicted by exceedingly inflated costs and inaccessible care for the ordinary citizen of India? The extant healthcare delivery models are based on “Modern Medicine”, wherein health relies on a mechanistic, insular, simplistic, analysis on which intervention is based, even when supported by questionable research. The bulk of published health science research and health policy guidelines are influenced by a purely biomedical construct. In recent times, more of published research is available through the internet. And yet, very little of this evidence translates into better care for patients without a long delay. Very few health providers are able or willing to practice evidence-based care. This is rooted in a healthcare education and training culture that is a patronizing, chauvinistic, and prescriptive practice of doling out healthcare in both the private and the public sectors.
Evidence is the best guide to any intervention, both diagnostic and therapeutic, with the desired outcome of improvement in health. Evidence based care makes it imperative to treat every clinical encounter as a trial where careful longitudinal follow up with meticulous attention to clinical impact determines the value of any intervention. The systematic evaluation of data driven analysis of outcome allows for an objective analytic framework delivering the most appropriate inference.
Data driven formation and analysis of evidence, practiced over a significant length of time, leads to accumulation of knowledge that translates into superior acumen in clinical problem solving and in the correct analysis and interpretation of data. Applying informal pattern recognition sometimes, characterized as “Intuition”, is more appropriately considered a form of applied “logistic regression”. When done with very large data sets, our colleagues in the IT industry call it “Machine Learning.” With the right algorithms and training of the system to “Learn” we have “Artificial Intelligence.” When done well, without sophisticated computer technology, as practiced by the exceptionally skilled clinician and health scientist it is “Real Intelligence.” This still needs to be complemented by an absolute commitment to unreserved benevolence over the self-interest of the health professional. The system must deliver a compassionate continuum of care for individuals, families, and the community. In providing health services, the inherent power differential imposed by a knowledge gap between health professionals and lay people distorts any determination of value vis-a-vis the price. While selecting health providers/services, we are left with few reliable parameters to judge who and what is the best for those who need health services.
A partial explanation of the overly medicalized system of healthcare lies in the fact that, historically healthcare professionals are trained in disciplines with a purely biomedical construct, with little appreciation for the environmental and social determinants of health. The paradigm of “Pathogenesis” encourages an “objective” attitude towards medical problem solving, similar to taking apart a malfunctioning machine and replacing its defective parts!
Health delivery has evolved into a series of multiple equations creating a “complicated” system. Alarmed by the burden of incomprehensible interventions and skyrocketing cost of medical care, society has started demanding “efficiency” in an increasingly unaffordable system. The campaign for cost reduction creates very often a perverse incentive to eliminate investment and many interventions even at the expense of safety and quality. The pursuit of cost effectiveness has unwittingly encouraged everyone to “know” the price rather than the “value” of health-related investments/interventions. No wonder most encounters with the healthcare system are often deeply traumatic for the people it is supposed to serve and sometimes frustrating for the professionals who are forced to conform to the system.
Clearly the status quo is unacceptable and completely unsustainable, particularly for a country like India. It is necessary to understand that health and any system that seeks to reform healthcare must first acknowledge the inherent complexity of the system. Life and “Health” as we know it, is a complex adaptive system best described as an amalgam of nonlinear equations that, taken together, are auto catalytic and autopoietic, as suggested by Stuart Kaufman[1]. Incorporating ethical and cultural dimensions of healthcare is integral to restoring confidence in the art of health professionals providing value to society.
Improving health of individuals, families, and communities requires a participatory action toward building a shared vision for a purposeful life with autonomy and dignity for all. An imperative is the elimination of the power differential between health providers and lay people. Empowerment of lay people to take control of their own health needs a paradigm shift by embracing “SALUTOGENESIS” [2] which is the “formation of health.” Health is fundamentally more than a purely biomedical construct. We need to change our focus from “disease”, using an analytic framework anchored in pathogenesis, to salutogenesis where the focus is on the ability to meet the demands of life. HealthEase, requires integration of biological (innate and acquired) attributes of individuals with the demands of life in the context of the environment including social determinants of health.
“HealthEase” the converse of “DisEase” translates into health best promoted by a sense of coherence having three essential components (1) Comprehension: A clear and shared understanding of the complete condition. (2) Capacity: An ability to cope with the condition. (3) Capability: An ability to have a purposeful life with autonomy and dignity.
At this point, I shall segue into the application of the concept of salutogenesis, to population health. The COVID-19 pandemic has reinforced what some kept reiterating for decades. To address population health, we must dispense with the false dichotomy between contagious/communicable diseases and non-communicable disease. Applied to populations, an obvious implication of this paradigm is the integration of the environment; animal health and human health into a continuum as the only way to promote human population health. This is “One Health”[3], anchored in social justice.
A historical illustration of ‘One Health’ is the analysis of the Aztecs and the Incas, a flourishing civilization of more than 24 million and 12 million respectively. Advanced in mathematics, astronomy, and engineering, they were stressed by ecological damage reducing food supplies causing societal distress. It is in this background, that they encountered Hernan Cortez and Francisco Pizzaro along with a few hundred semi barbarian conquistadors who smelled so bad that the locals had to “hold their noses.” The invaders brought with them firearms. However, the military significance of this technology against a standing army of tens of thousands is open to debate. The reality is that these guns were muzzle loaders, cumbersome, took considerable time to load and when fired was as likely to injure the user as the target. What the invaders brought with them was far more deadly: measles, chickenpox, and smallpox, that crippled the local population including the elite. In 50 years, the combined population of the Aztecs and the Incas, declined to less than 4 million pointing to a “A Demographic Collapse”. The complete annihilation of a sophisticated culture was replaced by the alien culture of the Spaniards. Whether this represents “salvation of the heathen” is off course open to debate [4].
There are other examples: HIV in sub-Saharan Africa, and most recently the global catastrophe caused by COVID-19. Although lesser in magnitude, the problem of rabies in India presents an illustrative case of the need to address the environment (garbage provides food for feral dogs and is responsible for increase in the population of dogs), unvaccinated dogs biting children is the most common cause of rabies in India. Poor access to prompt and appropriate care of dog bites particularly in rural areas contribute to an estimated ten thousand to fifteen thousand (verbal autopsy data) human deaths annually in India [5].
Now, are we necessarily the completely helpless victims of a destiny imposed by a capricious design of nature or malevolent entities beyond our comprehension or control? Allow me to suggest to you that what we have experienced and will continue to encounter is predictable at least in part, and certainly some of it is mathematically inevitable. COVID-19 is merely the most recent warning from mother nature, and we ignore it at our own peril.
In conclusion, we need to be more introspective as advocates of healthcare and move away from an inflated cost, fragmented, overly medicalized, technology intensive system to one embracing salutogenesis as the path to “One Health” anchored in Social Justice. A truly participatory action strategy is devoid of distortions imposed by differentials in knowledge, wealth and power or discrimination of any kind. We need to transition to being partners in care rather than mere purveyors of medical service. It is only mutual respect; building a shared vision that allows us to gain the trust of our people (individuals or populations) This is necessarily a journey rather than a destination where we must remember Mahatma Gandhi exhorting us “Be the change you want to see in the world.” Finally, in all humility we are reminded of the quote of Sir Patrick Cullen from the 1906 play “The Doctor’s Dilemma” by George Bernard Shaw “All professions are a conspiracy against the laity”.
Dr Vijay V. Yeldandi
M.D, FACP, FCCP, FIDSA
www.shareindia.org
References:
[1] A World Beyond Physics: The Emergence and Evolution of Life. 25 July 2019. Stuart A. Kauffman ISBN-10: 0190871334
[2] Vinje HF, Langeland E, Bull T. Aaron Antonovsky’s Development of Salutogenesis, 1979 to 1994. 2016 Sep 3. In: Mittelmark MB, Sagy S, Eriksson M, et al., editors. The Handbook of Salutogenesis [Internet]. Cham (CH): Springer; 2017. Chapter 4. Available from: https://www.ncbi.nlm.nih.gov/books/NBK435860/ doi: 10.1007/978-3-319-04600-6_4
[3] One Health is a collaborative, multisectoral, and transdisciplinary approach — working at the local, regional, national, and global levels — with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment. https://www.cdc.gov/onehealth/basics/index.html
[4] Disease and Development in Historical Perspective by D Acemoglu · 2003. https://scholar.harvard.edu › files › jr_diseasedev
[5] Suraweera W, Morris SK, Kumar R, Warrell DA, Warrell MJ, Jha P; Million Death Study Collaborators. Deaths from symptomatically identifiable furious rabies in India: a nationally representative mortality survey. PLoS Negl Trop Dis. 2012;6(10):e1847. doi: 10.1371/journal.pntd.0001847. Epub 2012 Oct 4. PMID: 23056661; PMCID: PMC3464588.
https://www.youtube.com/watch?v=oDQyeMAkA8k&t=18s
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https://www.youtube.com/watch?v=Vqs5sLskMWM
https://www.youtube.com/watch?v=FcJCCdbACkA&t=13s
https://www.happenforonehealth.org
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