Defining and Achieving Health: Looking Beyond the Usual Suspects
By: Ana Maria Lopez, M.D., M.P.H. | Apr 22, 2015 7:00 AM
Humans are living longer, healthier lives and our modern health system can take a share of the credit. Antibiotics, vaccines, imaging technologies, targeted cancer therapies, and interventions for stroke and heart disease are just some of the medical advances to have dramatically and measurably prolonged and improved our quality of life. Credit, of course, also goes to modern plumbing and agriculture (access to clean water and healthy food), public health campaigns, such as the anti-tobacco movement, reduced poverty and education.
Today, the lines between those medical and non-medical advances are blurring as health professionals grapple with a growing burden of chronic disease tied to environmental influences (including diet and exercise) largely beyond their control. Increasingly, clinicians are having to reevaluate and redefine the business of health care. What is health? Whose responsibility is it? Who should our partners be and what is our role in the communities we serve?
Ana Maria Lopez, M.D., M.P.H., the University of Utah’s new Associate Vice President for Health Equity and Inclusion and Director of Cancer Health Equity at Huntsman Cancer Institute, is challenging our health system to ponder those questions. I asked her to share some thoughts, and frame our collective inquiry with the following guest blog.
What is health? Is it something that you innately recognize when you encounter it, or something you only appreciate when you don't have it? Is it the absence of disease, or a measure of wellness and fitness? Is it simply in the eye of the beholder? And who is the beholder?
In this era of collaboration – translational discoveries, team-based care, affiliation partnerships, and optimized care coordination through the patient-centered medical home – we clinicians are challenged to engage another voice in the health care dialogue, the voice of the patient.
A recent poll by the Robert Wood Johnson Foundation and NPR recently did just that and explored health through the eyes of the patient. Although the study participants were not experts in health policy or community health, they outlined health priorities based on their lived experience and in a way that was surprisingly consistent with known social determinants of health. The patient lens was revelatory.
Given a list of 14 items, and asked which mattered most to their health, patients ranked “access to care” No. 1. Patients are well aware of the limitations that lack of access to care imposes. Necessary and essential, but not sufficient for health, access to care was followed by personal behavior, viruses/bacteria, stress, and pollution.
Perhaps most surprising to policy makers, payers, and clinical teams, who often raise the issue of patient "compliance" as the cause of treatment failure, was patients’ acknowledgement of the importance of personal behavior in achieving health. If patients are indeed willing to look at behavior and take responsibility, how does that shift the dialogue? Health care teams must not only be ready to provide patients with accurate and meaningful information about illnesses linked to lifestyle choices (2/3 of cancers are likely preventable with lifestyle interventions), they must be ready to engage the patient and her/his family in a path to behavioral change that is value congruent and culturally consistent.
Infection was the next risk identified. At the turn of the last century, infectious diseases were not only risky, they were often deadly. With the dawn of antibiotics, we have become somewhat complacent with nervous jokes about the deadly resistant bugs that the injudicious use of antibiotics promotes. Infections can still bring a shudder to civilization as our recent experience with Ebola reminds us.
Stress was noted next as a significant determinant of health. As we learn more about the power of the mind-body interaction, the flaw in thinking that separates mind and body becomes more evident. Yet, given the pace of life, many respond to the concept of de-stressing as an unrealistic, or unachievable, goal. The fact that patients rank stress just below infections may indicate a willingness to give stress reduction a try. If so, how equipped are we as health professionals to prescribe evidence-based interventions? How responsive are our health care systems in listening and tending to stress? How effective are we as role models for managing our own stress and promoting healthy behaviors?
The 5th identified priority –– pollution –– may seem to be outside the sphere of health care. Growing up in Chicago, however, I remember our community coming together as children, teachers, and parents to: limit our gas emissions by walking more and driving less; set up trash pick-up brigades; do can and newspaper recycling drives; and take early morning trips to the forest preserves to "sweep" the forest and clean the brooks. We came together as a team, to take responsibility and turn the tide. When translated to health care, this collaborative approach preempts the passive patient model of care and presupposes a partnership between the patient, the community, and the clinical team.
Finally, another finding of RWJF study that encourages fuller provider participation in health promotion is that those whose lived experience had brought them in touch with the social determinants of health were more likely to have an accurate perception of their significance. And those whose lived experience had sheltered them from the difficulties of access to care, who found it easier to find fresh vegetables and exercise daily, and who did not see the ravages of pollution in their daily life, were less likely to be aware of the significance of these factors on health and illness.
Why is this important? Because as colleges of medicine become affordable only to those whose incomes are well above the mean, and clinical teams emerge from populations with less lived experience with the social determinants of health, our clinical teams may be less likely to recognize the significance of these factors in the lives of their patients and communities they serve. This comes with added responsibility for academic health centers that train tomorrow’s health care professionals. We must educate our students and trainees to recognize, discuss, and ameliorate the negative impact of these factors on health.
Health care systems have a tremendous opportunity and responsibility to improve health and well being by purposely addressing cultural and socio-economic factors that influence health and illness. By taking seriously the patient voice and intentionally targeting factors beyond the prescription, we can revolutionize health care delivery, improve care, promote wellness and decrease health care costs for all.