{"id":36699,"date":"2016-05-19T10:01:41","date_gmt":"2016-05-19T09:01:41","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=36699"},"modified":"2016-05-19T10:01:41","modified_gmt":"2016-05-19T09:01:41","slug":"richard-smith-returning-health-to-the-people","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2016\/05\/19\/richard-smith-returning-health-to-the-people\/","title":{"rendered":"Richard Smith: Returning health to the people"},"content":{"rendered":"

\"richard_smith_2014\"<\/a>For the first two million years of humans there were no doctors. People were born, flourished, became sick, suffered, and then died without doctors. Probably there were healers who danced, sang, rattled skulls, and used herbs but managed without microscopes and randomised trials. \u201cScientific doctors\u201d appeared recently, and quickly\u2014according to Ivan Illich, the critic of industrial society\u2014\u201cexpropriated\u201d health from the people. Now the Creating Health Collaborative<\/a> wants to hand health back to the people. Can they possibly succeed?<\/p>\n

The expropriation of health
\n<\/strong>
\nIvan Illich began his 1975 book Medical Nemesis<\/em> (the forerunner of Limits to Medicine<\/em>) with the sentence:<\/p>\n

\u201cThe medical establishment has become a major threat to health.<\/em>\u201d<\/p>\n

I heard him lecture in Edinburgh in 1974 when a medical student and have never been the same since. The core of his argument was that medicine had falsely promised people that it could defeat the human eternals of pain, sickness, and even death. In doing so it displaced cultural mechanisms through which people endured and made sense of pain, sickness, and death. Medicine could not deliver on its promise and leaves people unable to make sense of what happens to them; they are converted from autonomous, responsible, coping, free individuals to consumers of the increasing range of technologies medicine has to offer. Pain, impairment, and death are transformed from \u201ca personal challenge into a technical problem.\u201d Nobody is dead until a doctor declares them dead.<\/p>\n

Ancient Chinese doctors were paid only when their patients were well, but modern doctors have little interest in health. Sickness is their business, and the old joke that the only healthy person is one who hasn\u2019t been adequately investigated is almost true: half the population has hypertension, half is overweight or obese, a third has a mental health problem. The Diagnostic and Statistical Manual of Mental Disorders<\/em>, the \u201cBible of psychiatrists,\u201d lists over 300 mental disorders. Yet life expectancy has been steadily increasing in most countries, although in high income countries the length of unhealthy life has increased faster. \u201cUnhealthy life\u201d now lasts over 20 years for women in the UK, starting soon after 60 and lasting until death in their 80s. Is this progress?<\/p>\n

As the global medical empire expands it consumes more and more resources. The US spent 5% of its gross domestic product on healthcare in 1960, but this had risen to 17.5% by 2014. Uwe Reinhardt, a professor of health economics, jokes that eventually everybody in the US will either be working in a hospital or be a patient in one. Other countries do not spend so much, but the upward trend is the same everywhere. Expenditure on healthcare crowds out expenditure on education, housing, transport, the environment, and social care\u2014many of which may be more important determinants of health than healthcare, which is really sickness care. Despite the huge expenditure health systems in high income countries are proving unaffordable, and sadly many low and middle income countries are following the same trajectory\u2014instead of re-envisioning health systems.<\/p>\n

Creating health
\n<\/strong>
\nAgainst this backcloth the pioneers who comprise the Creating Health Collaborative<\/a> are trying to find a route to a saner, more sustainable health system that is primarily about health rather than managing sickness. They don\u2019t imagine closing down the sickness system, but they aim for a better balance. They concede that they don\u2019t know how to do this, but many experiments are underway. There will not be one way but many.<\/p>\n

Rightly to my mind they think that the way forward lies not with individuals or political systems (although there may need to be political changes later in the process) but with communities. Their report<\/a> outlines 11 principles for creating health and summarises experiments that are happening now. Carefully recording and evaluating these experiments will increase understanding.<\/p>\n

What is this health we are trying to create?
\n<\/strong>
\nAny attempt to create health must, you might think, arrive at an agreement on what is meant by health. This is not so easy. For those professionals who work in health, even public health officials, health is effectively defined through the \u201cdeficit model\u201d\u2014if the person doesn\u2019t have a disease that we can define then he or she is \u201chealthy.\u201d WHO has its grandiose definition of \u201ca state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.\u201d Such a state is rarely reached by any of us, but the definition does have the advantage of making clear that health is not merely the negative state of not having a diagnosed disease (although at the same time illustrating that that\u2019s how health professionals did think, and many still do in practice).<\/p>\n

I was part of a group that attempted a new definition and arrived not at a precise set of words but a move \u201ctowards the ability to adapt and self manage in the face of social, physical, and emotional challenges.\u201d This is close to Illich\u2019s 1974 conception of health as \u201cthe intensity of autonomous coping ability,\u201d but in an introduction to a 1995 edition of Limits to Medicine<\/em> Illich rejected that definition: \u201cI neglected the transformation of the experience of body and soul when wellbeing comes to be expressed by a term that implies functions, feedback, and their regulation.\u201d I don\u2019t fully understand this, but I think that Illich worried that his original definition means that people would fall back into the arms of health or system engineers. Illich wasn\u2019t keen on professionals, and I\u2019m by no means sure that he would have been an enthusiastic member of the Collaborative.<\/p>\n

This debate over what is health is akin to the debates over what are art, poetry, freedom, or happiness. There never can be an agreed operational definition, and the Creating Health Collaborative sidestep the problem by declaring that health is whatever a community defines it to be. If it\u2019s the removal of dog shit and the installation of street lamps, then that\u2019s what it is\u2014and the community finding a way to make that happen will in itself be a health-creating process. Indeed, the process may be closer to health than the outcome. (Perhaps the word health is being stretched to a point where it\u2019s no longer useful at all, perhaps a problem for a collaborative that is trying to create it.)<\/p>\n

Searching for my community
\n<\/strong>
\nAlthough I\u2019ve confidently declared that community is the right level to intervene, I\u2019m not sure how I\u2019d characterise \u201cmy community.\u201d I live in a big house in a well to do street in Lambeth. I know quite a few people in the street, and some I\u2019m sure would come to my funeral or even bring me soup if I become ill. Tomorrow I\u2019m going to a street party, but I know that mutual loathing will stop some people going and may put a chill on the party. The street doesn\u2019t seem to be my community. Recently\u00a0I voted in the London elections, but I can\u2019t conceive of my ward, borough, or city as my community. Perhaps it\u2019s the people I have most contact with, but most of the contact is electronic\u2014and the people are scattered around the world. That can\u2019t be a sensible \u201ccommunity\u201d in which to intervene to create health.
\nSo I\u2019m left with the worry that the collaborative is mostly concerned with \u201cpoor folks,\u201d not rich people like me. Perhaps that\u2019s not a problem because poorer people have much higher levels of ill health. We rich can look after ourselves, but any enterprise that concentrates purely on the poor runs the risk of being patronising and creating stigma.<\/p>\n

Experiment and report back
\n<\/strong>
\nThe Collaborative can\u2019t define community beyond favouring \u201can inclusive definition,\u201d so perhaps we shouldn\u2019t pay too much attention to a Collaborative that can\u2019t define what it is trying to create nor the space within which it is trying to create it. But that would be a mistake. The Collaborative is trying to do something difficult, return health to the people, and this is a hugely complex task, one that was beyond Illich, who was a thinker not a doer. The Collaborative is rightly putting the emphasis on doing\u2014and then reporting back on its learning.<\/p>\n

Their recent report<\/a> should be read as a report back with all the uncertainty that learning implies. \u201cIn order to arrive at what you do not know,\u201d writes T S Eliot, \u201cYou must go by a way which is the way of ignorance.\u201d Embracing our ignorance is the first step to learning.<\/p>\n

Richard Smith<\/strong> was the editor of <\/em>The BMJ until 2004.\u00a0<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

For the first two million years of humans there were no doctors. People were born, flourished, became sick, suffered, and then died without doctors. Probably there were healers who danced, […]<\/p>\n

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