I am reproducing another article by Dr K S Jacob from The Hindu dated 20th June. After reading this I have to ask myself "Are doctors promoting health in the community OR Are we just merchants selling health as a commodity ?". Please read on and give your commentsPublic health and the clash of cultures
K.S. Jacob
The varied disciplines involved with public health, their divergent frameworks result in different agendas. The public-private partnerships are suggestive of collusion between the stakeholders and actors with the public health agenda hijacked by powerful private players.
Health is now a major priority on the international agenda and is an imperative for development. Despite advances in some developing countries, much still needs to be achieved in many nations.Determinants of health: The relationship between poverty and disease had long been acknowledged by public health reformers. Progressive groups within the movement advocated reform and enlisted many inputs — political, financial, social, cultural, engineering, science, educational, religious, and legal in addition to medical — to be part of efforts to improve the health of populations. The convergence of these disciplines is necessary for improvements in the health of populations. The public health perspective, thus, draws on a variety of disciplines. Consequently, it is not a discipline in the traditional sense.
The different context of public health: The public health movement in India relies on medical models with urgency-driven curative medical solutions which have always been short-term fixes and have resulted in the postponement of permanent public health solutions. The easy availability of antibiotics and medication in the developing world mean that provision of clean water, improvements in sanitation, nutrition and housing, all of which are basic public health approaches, is always on the back burner.
Varied language, framework and cultures: The complex situation has resulted in poor public health systems. The multiple disciplines with their diverse ideology, frameworks and language have muddied the waters and have made progress slow. The medical fraternity and the pharmaceutical industry advocate the biomedical model with its preference for curative treatments. Their language includes symptoms, signs, investigations, diagnosis, medicines and treatment. On the other hand, financial institutions argue for and insist on the capitalistic model, which reflect their own concerns rather than those of population health. They view issues through a different set of idioms including economics, capital, collaterals, loans, interest, repayment schedules and penalties. The social science perspectives, major determinants of health, are often not considered key issues in actual practice and are marginalized. Political leaderships, with their short-term needs, prefer an electoral languag! e and immediate gains, with their focus on retaining power and addressing specific constituencies. Civil servants concentrate on planning, budgets, targets and manpower.The West brought about improvements in population health by providing a minimum standard of living for its citizens and yet insists that India focuses on specific problems rather than in improving the general public health infrastructure. Similarly, many international banks and aid agencies focus on curative heath care and side-step the fact that even minimal improvements in the health of populations are determined by social and economic factors and prefer to support vertical health programmes for particular diseases. Nevertheless, the absence of basic public health measures will ensure the persistence and re-emergence of the very diseases targeted (e.g. malaria, polio and tuberculosis). Politics and finance trump public health every time.
Shared objectives and divergent agendas: While many disciplines have public health as a goal and share public health objectives, their diverse backgrounds and models clearly support their divergent agendas. Financial institutions support initiatives which are profitable. For example, the provision of clean water and sanitation are much less profitable for the various actors involved, compared to the provision of medicines and vaccines. Despite several recent key reports which emphasize the dramatic health (and economic) benefits that can be gained from improvements in water and sanitation, such targets receive low priority in funding. On the other hand, vaccines (e.g. Haemophilus influenza B), which target diseases with much lower prevalence and that have much less impact on the health of populations, receive generous support.
Ownership and ability to deliver: Poor public health standards are a result of major problems related to ownership of the public health goal. The rise of the biomedical viewpoint over the last century has given medicine a much larger role in improving the health of populations than to its ability to deliver. With its focus on biology and drugs, it is not in any position to bring about the public health revolution necessary to have a significant impact on population health whose main determinants are social and economic. The other disciplines necessary to achieve the public health transformation do not take the lead as they lack a sense of ownership of the public health goal. The powerful perceptions and models within the constituent disciplines make public health professionals peripheral players. Public health needs to be a socio-political mass movement if any significant degree of success is to be achieved.
Basis of public health policy: Social justice and an egalitarian society are the essence of public health. The evidence base for medicine and policy are often used selectively to support specific models and frameworks. For example, while evidence is used to defend the introduction of vaccines for disease prevention, it is not employed to argue for interventions which use clean water, sanitation and nutrition which have a much greater impact on the health of populations. Similarly, the estimation of the global burden of disease, on which much of the arguments for funding are based, is controversial and is much less valuable in for use in developing countries as it does not reflect regional priorities.
Health and public health as a human right: The poor health status of populations is related to chronic poverty working through hunger, undernutrition, illiteracy, unsafe drinking water, social discrimination, physical insecurity and political exclusion. The promotion of health, and consequently of social and economic rights of the poor in India, is the most important human rights struggle of our times. While the west continues to focus on human rights in developing countries, the developed world refuses to acknowledge that public health is also a basic right and support its fulfilment. In fact, the failure to meet the public health needs of populations has become normalised across India and on the international stage. However, governments and international agencies often prefer to confine the debate to the issue of resources for medical treatment, as a means of deflecting the debate from the true social and economic causes of ill-health. The public health vision for the 21st! century needs new policies based on a human rights perspective to address the challenges of health needs of populations.
Possible direction: There is a need to differentiate public health as a discipline, a goal, an agenda, and as practice. The abuse of power among the many public health stakeholders and actors and its relationship to their financial clout needs careful review. The current public-private partnerships in public health in developing countries are more suggestive of collusion between the stakeholders and actors with the public health agenda hijacked by the powerful private players. The conflicts of interest and differentials in power within groups working on public health initiatives and their different ideologies, agendas and tensions should be acknowledged.Public health should be located within society and politics rather than within medicine. The majority of the priority health conditions in India require public health solutions (e.g. water, sanitation, nutrition, housing, education, employment, social protection) rather than medical and pharmaceutical interventions. However, the mainstreaming and scaling up of efforts in these areas requires political commitment for inter-sectoral dialogue, an ethical framework which views public health as a human right and resource allocation which examine issues through the public health lens.There is a need for a people’s movement which champions public health issues as basic rights. The current supply-side and top-down approach to public health needs be replaced by a bottom-up approach with community mobilisation for meaningful changes to occur. The challenge is to integrate public health goals into the diverse disciplinary frameworks and models.(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore. This article is based on his paper published in a recent issue of the Journal of Epidemiology and Community Health published by the BMJ group.)
The following story narrated by a fellow psychiatrist may remind us about John Nash - famous after 'A beautiful Mind'. Dr Singh is in many ways an Indian version of Nas, though his tale invokes much more sympathy in us. Very few people know about Dr.Vasistha Narayan Singh, a world renowned mathematician and an ex-NASA scientist, who has been suffering from schizophrenia since 1976. The mathematician who challenged works of Great Scientist Albert Einstien.Coming from a very poor family, he is the record holder for Matriculation and Intermediate Science Exam. In mathematics conference he had presented a list of 5 most difficult problems. He solved all of them and that too in different ways. Prof Berkley got impressed and requested him to come to USA for further study. Singh did not let down HOD and did his PhD with style and went on to work for NASA. He had nationalistic dreams and thought of doing his India proud rather that stay on in US as his HOD and NASA wanted him to do.He married to an army officer's daughter. Due to reasons unknown, marriage did not work out and his wife left him and never come back. This left him heartbroken and made his condition worse.He returned to India and worked at ISI Cal, IIT Kanpur and TIFR Mumbai. He had a tough time at ISI Cal and was disillusioned at other places also.Soon after that, He lost his mental balance and was admitted to Mental Hospital, Kanke, Ranchi. Mental Authority threw him out of Kanke and his family did not have enough money to support his treatment which made his condition worst. He was treated by NIMHANS but details are not available. It appears that he fled from Merut Mental Hospital and was untraceable for many years until someone from his village saw him as a rag picker in Chapra. Relatives were happy to see him alive but were sad to see his misery.Dr Singh was in Patna (April 2004) to take part in a function organized in his honor by an institute run in his name. Singh looked ruffled, probably unable to catch the lavish praises that were hurled upon him by the speakers present on the occasion. At times, he gave the most loving smile, like a child. However, he looked distracted most of the time, probably lost in his world where there is no scope of anything except maths. He did not seem interested even when his biography was released by former VC.His love for maths was more than visible, even now, when he is said to be mentally challenged. Even while coming to Patna, he had not forgotten to carry with himself his prized possessions (maths books, diaries filled with mathematical theories and formulae etc). He had tied all this in a neat heap and occasionally looking at it.Once when the mike was given to him to say something, he spoke indecipherable words about some mathematical topic. But his sensitivity did not appear lost.Recently, the Bihar government has sent him to New Delhi for treatment (April 2009).John Nash (brilliant mathematician and noble prize winner whose story was portrayed in the movie A Beautiful Mind) made a recovery from the schizophrenia from which he had suffered since 1959 but Dr Singh did not. Why?Some factors supporting recovery in case of Nash could be beneficial to Dr Singh’s case.The relationships Nash had with fellow mathematicians were essential to his eventual recovery, but the single most important factor in Nash's recovery was the bond with his remarkable wife, Alicia. She fed, housed and cared for him even after she divorced him, and never wavered in her devotion to him or her belief in his extraordinary talent.In Nash's case, the Princeton campus functioned as a therapeutic community. His bizarre behavior was mostly tolerated, and he was granted access to lecture halls and libraries and offered human contact without being forced to make it. As his schizophrenia receded, Nash participated in seminars and made friends with a few graduate students. Later he was given unrestricted access to a computer, which he taught himself to use, and began writing intricate programs. A reluctance to give up -- or to accept a prognosis of doom -- can be seen in Nash's story.http://timesofindia .indiatimes. com/articleshow/ 597829.cmshttp://in.answers. yahoo.com/ question/ index?qid= 20090120030204AA xvcnURegardsD N Mendhekar (09868 900 900)Pratap Nagar Metro Pillar 129, Delhi-7
From the fifth century AD until the past century, Galen's theory about the four humours ruled medicine. Its corollary was that the treatment of disease involved getting the humours back in order; releasing them through bloodletting was the most common procedure, often augmented by other means of freeing bodily fluids (e.g. purgatives and laxatives). For 14 centuries, physicians subscribed to this wondrous biological theory of disease: they bled their patients until they lost their entire blood supply; they forced them to puke and defecate and urinate; they alternated extremely hot showers with extremely frigid ones – all in the name of normalizing those humours . Yet, it all proved to be wrong.Most medieval Christian physicians believed that mental illness was caused by either demonic possession or as punishment from a god, which led to a negative attitude towards mental illness. On the other hand, Islamic ethics and theology held a more sympathetic attitude towards the mentally ill. Muslim physicians relied mostly on clinical observations. The first psychiatric hospitals were built in the medieval Islamic world from the 8th century. The first was built in Baghdad in 705, followed by Fes in the early 8th century, and Cairo in 800. They were the first to provide psychotherapy and moral treatment for mentally ill patients, in addition to other forms of treatment such as baths, drug medication, music therapy and occupational therapy. Such institutions could not exist in Europe at the time, because of European fears of demonic possession. The Persian physician Muhammad ibn Zakarīya Rāzi (Rhazes) (865-925) wrote the landmark texts El-Mansuri and Al-Hawi in the 10th century, which presented definitions, symptoms, and treatments combined psychological methods and physiological explanations to provide treatment to mentally ill patients. Avicenna (980-1037) was an early pioneer of neuropsychiatry, and first to described a number of neuropsychiatric conditions such as hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo and tremor. Avicenna identified LOVE SICKNESS (Ishq) when he was treating a very ill patient by "feeling the patient's pulse and reciting aloud to him the names of provinces, districts, towns, streets, and people." He noticed how the patient's pulse increased when certain names were mentioned, from which Avicenna deduced that the patient was in love with a girl whose home Avicenna was "able to locate by the digital examination. " Avicenna advised the patient to marry the girl he is in love with, and the patient soon recovered from his illness after his marriage. Avicenna also gave psychological explanations for certain somatic illnesses, and he always linked the physical and psychological illnesses together.Al-Kindi (801–873) was the first to realize the therapeutic value of music. He was the first to experiment with music therapy, and he attempted to cure a quadriplegic boy using this method.Later in the 9th century, al-Farabi also dealt with music therapy in his treatise Meanings of the Intellect, where he discussed the therapeutic effects of music on the soul.Ali ibn Sahl Rabban al-Tabari's Firdous al-Hikmah written in the 9th century was the first work to study 'al-‘ilaj al-nafs (translated as "psychotherapy" from Arabic) in the treatment of patients. His ideas were primarily influenced by early Islamic thought and ancient Indian physicians such as SUSHRUTA and CHARAKA.The Muslim physician Abu Zayd Ahmed ibn Sahl al-Balkhi (850-934) was a pioneer of al-‘ilaj al-nafs, and the first to compare "physical and psychological disorders" and show "their interaction in causing psychosomatic disorders.http://en.wikipedia .org/wiki/ Islamic_psycholo gyHaque, Amber (2004), "Psychology from Islamic Perspective: Contributions of Early Muslim Scholars and Challenges to Contemporary Muslim Psychologists" , Journal of Religion and Health 43 (4): 357-377.
This is in response to the article 'Bridging the disease-illness divide in medicine' by Dr K S Jacob.(Please see the previous post). The article raises an issue which occasionally confronts many doctors. Patients present to clinicians with various complaints which worry them. Usually they have a real disease which is detectable by objective methods. Sometimes it may be just a doubt whether the symptom has an ominous significance or not. At other times it may be just to seek reassurance that their symptom is of benign nature . Many patients also tend to express emotional distress in the form of bodily complaints. The job of the doctor is to evaluate the symptom and explain the nature of it to the patient in simple layman's language. If it needs some form of medical /physical /psychological treatment he is authorized to administer this by way of his training and license to practice. He may also refer the patient for further evaluation by special tests or by a specialist with better expertise. In the words of Sir William Osler the duty of the doctor is "To cure sometimes, to relieve often and to comfort always". These words still continue to be true, despite all the technological advances in curative medicine, as we are able to offer cure for only a minority of real diseases. When the venue of practice shifts to huge hospitals with profit motive, the priorities change. This escalates the costs of treatment and sometimes leads to iatrogenic complications. Kickbacks from the pharma and lab industry further complicate the situation.The medical training offered to a doctor does not make him always competent to develop the skills needed to evaluate and handle patients without any objective evidence of disease. He is trained to become a practitioner with a license to practise his profession and earn a livelihood out of it. He thinks his duty is to prescribe a pill for every ill that he comes across. Otherwise he may not get paid for his service. The time spend for educating the patient about his own body / health etc is considered a waste. There also time constraints because of huge patient load. He is not given adequate exposure in handling emotional problems or counseling regarding behavioral problems. When the venue of practice shifts to huge hospitals with profit motive, the priorities change. This escalates the costs of treatment and sometimes leads to iatrogenic complications. Kickbacks from the pharma and lab industry further complicate the situation. The whole system of giving medical training has to be revamped for this situation to change. The doctors should be trained to view themselves as counselors and educators of the public on matters relating to health and disease. There should be provision for getting timely, accurate information on one's condition and the remedies available. The system of fixing pay of doctors based on the revenue generated by them will also have to go. Many private / corporate hospitals use this method of paying doctors. Patients with subjective distress / discomfort in the absence of objective signs of disease have to be evaluated by a competent physician with adequate experience and training in bio medicine and psychosocial approaches. Majority of such patients are exploited by quacks, demigods and even by unscrupulous doctors. A recent addition to this group of exploiters are the self proclaimed nutrition and wellness therapists. They charge huge amounts and provide sham therapies which have no proven efficacy. Because these are delivered in posh, luxurious ambience by 'therapists' with good soft skills, the recipient is unaware that he is being duped.
The following is an article from The Hindu dated 12th June 2009.Bridging the disease-illness divide in medicine
K.S. Jacob
The failure to address issues related to the disease-illness dichotomy and the cure-healing divide and to bridge the gap between these part-perceptions is a major cause of patient dissatisfaction.
The increased cost of health care and the urban-centric nature of our health delivery system make it unaffordable and inaccessible to the majority of Indians. The health-hospital, pharmaceutical and medical education industries, which profit from disease and illness, also complicate the situation. These factors have resulted in dissatisfaction with quality of health care for the vast majority of the population and a crisis in health care in India. The problematic conceptualisation of disease and illness which underpins many of these issues is highlighted.
The disease-illness distinction: Disease and illness are commonly used as synonyms and clearly highlight the lack of conceptual clarity. Medical definitions of disease emphasize the pathological process and the deviation from the biological norm. Diseases are pathological entities conceptualised by physicians who offer scientific causal explanations and prescribe treatments with the aim to cure. Illness, on the other hand, is the patient’s experience of ill health, is influenced by culture and focuses on the relief of suffering.While there is an overlap between disease and illness, the divide persists because of the absence of a one-to-one relationship between disease and illness. Similar degrees of pathology generate different amounts of pain and distress. The course of a disease can be different from the trajectory of an illness. In addition, illness can also occur in the absence of disease (for example, medically unexplained physical symptoms causing distress). These result in differences in perspectives about the condition between doctors and their patients.
Modern medicine in perspective: Recent advances in medicine have made curative treatments an attractive option. However, modern medicine has limitations including its narrow focus in making disease more important and interesting than illness and a single-minded pursuit of cure. Physicians often disregard the patient’s interpretation and explanations and discount the human context of illness.Physicians are taught to focus on underlying structural and functional defects and often tend to ignore the impact of the illness on the patient’s life. Partial understanding of conditions (e.g. hypertension), or occasionally complete ignorance (e.g. myalgia, somatisation disorder), results in symptomatic treatment. However, the ubiquitous use of medical jargon suggests that the scientific halo, reserved for the few conditions which we now comprehend reasonably well, is indiscriminately applied to all forms of human distress.Such a divergent focus results in dissonance between doctors and their patients. While doctors highlight naturalistic explanations for a disease (such as abnormality, degeneration, infection, malignant change), patients focus on personalistic beliefs about causation (such as beliefs in karma, sin, punishment, evil spirits, black magic, supernatural explanations). Many patients seem to simultaneously hold naturalistic explanations about disease as well as personalistic perspectives on illness, despite the apparent contradictions. Patients and their relatives also concurrently seek diverse interventions—medical and non-medical. Hospitals which practise modern medicine compete with facilities which offer faith healing and traditional systems of medicine. People with illness who fail to respond to traditional methods of healing visit allopathic centres with reasonable success and vice versa.Diverse systems of medicine and healing flourish in India. While significant technological advances have had a major impact on the health of individuals, many other issues also seem to define health and disease. Financial gain for doctors and hospitals, niche markets for the pharmaceutical industry, insurance reimbursements and opportunities for academics also influence disease categorisation. While there has been much progress, many so-called advances are illusions. Many new disease categories are introduced without adequate scientific evidence. Re-categorisation of existing entities without adequate basis is also common. In addition, expensive new drugs with no real improvement in efficacy give an impression of superior solutions. Although medical advances have resulted in significant improvement in the health of individuals, many indices of the health of populations suggest major unsolved problems (such as malnutrition, shorter life span, infant and maternal mortality ass! ociated with the poorer sections of Indian society).
The success of traditional and folk medicine: Traditional and folk systems of medicine, despite their lack of scientific rigor, continue to enjoy the confidence of the general population. Their success can be attributed to their focus on the illness experience. Their practitioners seem to successfully elicit, offer and negotiate explanations and expectations with their patients. Traditional healers share symbols and metaphors consistent with lay beliefs and their healing rituals are more in tune with the psychosocial context of illness.
The need for a new conceptualisation: Doctors can learn many lessons from traditional healers and indigenous medicine. These include the fact that many patients suffer from no/minor disease. They need to understand that the illness experience dominates patient reality. Consequently, physicians need to appreciate that the sole focus on disease and cure undermines illness experience and the need for healing.While traditional healers are effective in treating illness, they may less frequently influence the course of the disease. On the other hand, modern medicine and physicians can potentially treat both illness and disease. Doctors need to elicit patient perspectives about the illness, its impact on their life and their expectations. They should present biomedical perspectives as an alternate reality without claiming exclusivity. They must negotiate a treatment plan keeping cultural issues in mind. Health care is often less than satisfactory and treatment less effective when only disease is treated rather than when both disease and illness are managed together. Poor compliance, poor clinical care and medico-legal problems are often due to discrepancies between patients’ and doctors’ views of clinical reality.Many problems presenting to doctors are now viewed from a specialist perspective. The progressive medicalisation of distress has lowered thresholds for the tolerance of mild symptoms and for seeking medical attention for such complaints. Patients visit general practitioners and physicians when they are disturbed or distressed, when they are in pain or are worried about the implication of their symptoms. However, the provision of support currently mandates the need for medical models, labels and treatments to justify medical input.The divergent frameworks employed to view the clinical reality of disease or illness artificially forces the divide. There is a need to view disease-illness issues through alternating medical and patient lenses in order to see the full picture. Both the disease and illness perspectives are partial truths and need to be managed simultaneously for cure and/ or for healing. Rapid alternation between the two frameworks and perspectives will result in the delivery of holistic care.Doctors need to accept multiple approaches to restoring health and should encourage the use of diverse strategies to restore health and improve functioning. The disease-cure and the illness-healing models are part-perceptions of the whole and result in a gap in communication between doctors and their patients. This seems to be made worse by medical technology widening the gap between what patients seek and what doctors provide, causing dissatisfaction. Good doctors know the difference between disease, illness, healing and cure. They also know how to manage them.(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)
