(by Geoffrey Frankson MBBS, MA (Oxon))
The outstanding challenge to the architects of a modern health care system is the change in patterns of disease and disability that has taken place over the last fifty years or so.
In all, except the least developed societies, people are living longer (largely due to a decreased likelihood of premature death from acute, infectious disease, accidents or violence) and modernising their lifestyles to include: 1) a higher energy intake – primarily from animal fats, oils and simple carbohydrates, 2) less physical exertion – especially less walking and less manual work, and 3) more stress – rooted in rapid rates of change in the social environment.
Modern patterns of morbidity are a direct result of these lifestyle changes, and the medical and social consequences are a high and growing prevalence of obesity, type II diabetes mellitus, certain types of cancer, hypertension, cardiovascular diseases, venereal diseases, substance abuse, domestic violence, accidents and social displacement. Among the elderly, even when they have escaped serious illness, modern lifestyles are leading to a lower quality of well-being, largely due to poor physical strength and a reduced role in the social and economic life of the society.
Lifestyle, then, has become the main determinant of the well-being of the people. Social and economic progress has led to greater freedom of choice for communities, families and individuals, and ultimately, it is choices about the physical and social environment, the food supply and opportunities for exercise and relaxation that will determine the standard of health that the population enjoys.
Left to their own devices, people are inclined to drift in a negative direction where their personal health habits are concerned.
Instinctively – and perhaps genetically – they seek to maximise energy intake and minimise energy output. They strive for advantage in social relationships, and look for short-term rewards in their economic practices.
Strong “traditional” value systems counter these tendencies by guiding – and even restricting – personal choice. Freedom from such traditional constraints in modern society leads to poor decision-making and consequently, lower standards of health and well-being compounded by weak social support.
The challenge for modern health care providers is to influence lifestyle decisions in a positive direction without compromising freedom of choice. They have to find ways to induce people to strive for higher standards of health at the personal and community level; in other words, to replace “survival” values with “growth” values.
Higher standards of health require efforts that incorporate, but go well beyond preventative measures such as hygiene and immunisation, protective measures such as public health and safety regulations, and medical measures such as early detection and better treatment of disease. It requires that individuals, whether or not they are free from disease and disability, seek to be properly nourished, physically leaner and stronger, better balanced socially and emotionally, and personally happier and more productive.
The prevailing “health system” is entirely inappropriate for this challenge, based as it is on a paradigm in which people will presumably be healthier if their problems can be solved by experts and bureaucrats; that is, if their diseases are properly treated, their food supply secure, the laws regulating their lives enforced, and their cultural and recreational facilities constructed. It continues to place more responsibility on the system than on the individual, hence the prevailing attempt to improve the system by shifting the emphasis to primary health care while leaving the paradigm intact.
An appropriate health system would have an entirely different emphasis. It would be centred on health promotion for all rather than on medical treatment for the sick, social support for the displaced and welfare for the indigent. This is a different paradigm from the foregoing since this system is predicated on personal responsibility and holds “care” of any kind to be a means to an end rather than an end in itself. Success is measured with indices of wellness, and the measurements take place, not in institutions or health care centres but in communities.
In such a system, the economics of health goes beyond a reactive search for funds to treat problems to a proactive investment of funds in health inducing activities.
While the avoidance of suffering has had and will always have the highest priority when it comes to the apportioning of funds in the national budget, it is important to note that, in the modern era, such expenditure is not a means to higher standards of health for a whole population.
Indeed, if it leads to reduced expenditure on genuine health promoting activities, it will be self-defeating in the long term.