Health what is health

1
Health what is health?

• Define health illness - difficulties in doing
  this
• Changing ideas about health illness illness
  may perceive people as dependent.
• Medical model and other models

2

• 1. What does health mean to you personally
• 2. What do you understand by the term health?

3
Defining Health

• WHO 1948 Health is a state of complete
  physical, mental and social well-being and not
  merely the absence of disease or infirmity
• Parsons 1972 the state of optimum capacity of
  an individual for the effective performance of
  the roles and tasks for which he/she has been
  socialized.
• choices in relation to health at both a society
  and individual level how can good health be
  maintained, poor health be prevented and how
  should those who are sick or disabled be cared
  for

4
A paradox

• Health is improving knowledge is growing
• but the complexity of health care is growing .
• our uncertainty about how to respond has never
  been greater

5
Lay beliefs

• shaped by culture considerable variations
  depending on gender, ethnicity, social class, age
  experience with ill-health
• Class working compared with middle class
• Gender lifecourse
• Younger men physical strength,
• Younger women energy vitality, ability to
  cope
• Middle aged mental well-being, contentment
• Women broad social relationships (Blaxter 1990)
• Cultural
• Asians tend to define health functionally,
• African-Caribbeans tend to attribute illness to
  bad-luck

6
Lay concepts of health

• Negative health as the absence of disease
• Functional health as ability to function in
  normal everyday roles
• Positive health as general well-being/equilibrium

7
Why study lay concepts of health illness?

• Inherently interesting
• What influences peoples health illness
  behaviour?
• Crucial to patient-professional relations
  partnerships in health care
• Influence satisfaction with health care
• Important for health promotion

8
Biomedicine

• Biomedical model emerged late C18th early
  medicine included theories practices based on
  imbalances within the body.
• Disease located within particular organs,
  discovery of specific causes (e.g.
  micro-organisms) specific diseases e.g. cancer,
  heart disease, HIV/AIDS
• Biomedical model uses mechanistic curative
  approaches
• Biomedical power - medical dominance in health
  care
• Relationship between social inequality illness
  not considered

9
Key features of the biomedical model (Mishler
1989)

• Illness as a deviation from normal biological
  functioning
• Doctrine of specific aetiology (cause)
• Generic nature of disease
• Medicine as scientific, neutral value free

10

• health seen as absence of diagnosable disease
• identifiable diseases have specific, biological
  causes
• doctors defeat illness by finding specific
  counter remedies medicine
• patients role is to cooperate with doctors
  (passive)
• prevention - individual responsibility to avoid
  risky behaviour
• medical progress winning battle

11

• Biomedical model is a mechanistic view of the
  body where ill health is treated as the
  mechanical failure of some part of the systems of
  the body and the medical task is to repair the
  damage Doyal 1995.
• Defining a problem in medical terms, using
  medical language to describe the problem,
  adopting a medical framework to understand a
  problem, or using a medical intervention to treat
  it (Conrad 1992)
• No need to consider the wider social inequalities
  which contribute to health status.

12
Challenges to biomedicine

• holistic health systems alternative or
  complementary medicine
• self-help, consumerism, patient empowerment how
  far can patients take over?
• Reform of health care
• politics of prevention a new public health ?

13
Alternative models to the biomedical model

• Holistic
• Interaction of body and mind
• Multi-causality
• Socially connected individual
• Prevention health promotion/maintenance

14
Social determinants

• (un)employment, class, poverty, housing, food,
  socio-economic determinants results in ? policy
  range
• poverty, income, tax and benefits
• education
• employment
• housing environment
• mobility, transport pollution
• nutrition Common Agricultural Policy
• mothers, children families, young adults, older
• ethnicity
• gender
• stress

15
Criticism of biomedicine

• What role did medicine play in the decline of
  infectious disease? (McKeown 1979)How effective
  is modern day medicine? (evidence based medicine,
  RCTs etc.)

16
Vaccination effective or not?

• Data on some diseases, e.g. TB, show
• decline before the introduction of
• vaccination. (see graph)
• McKeown argues that nutrition improved social
  economic circumstances led to a decline in
  infectious diseases (not vaccination)
• (McKeowns chapt 39 in Davey et al)

17
Critical perspective- evidence
18
Decline in mortality from tuberculosis in
England Wales over time
19
Efficacy of biomedical model?

• immunization treatment contributed little to
  the reduction of deaths from infectious diseases
  before 1935, over the period since cause of
  death was first registered (in 1838) they were
  much less important than other influences e.g.
  nutrition.
• McKeown, (1976) in Davey et al, (2001) p218

20
Medicine - an institution of social control?

• Normal for whom? Shifting boundaries between
  normality deviance over time.
• Multiple causation of (chronic) disease, general
  susceptibility to disease
• Diseases are socially, culturally historically
  variablesocial construction of diseases over
  timenew emerging disorders.
• Rather than standing outside of society medicine
  is deeply embedded within it.
• Biomedical model is one version of reality rather
  than the reality

21
Biomedicine critique by Illich

• Medicine is a serious threat to our health
  coined the phrase iatrogenesisGreek, physician
  (iatros) created (genesis).
• three different types of iatrogenesis
• clinical (medical incompetence/mistakes)
• social (artificial need for medical products)
• Structural/cultural (undermining autonomy
  competence)
• Ivan Illich Limits to Medicine (1976)

22
Clinical iatrogenesis

• In 60s increase in childhood cancers linked to
  routine x-rays of pregnant women
• Junior aspirin known to kill children since 1963
  but not banned till 1986
• More than 50 of antibiotic prescriptions
  unnecessary

23
Clinical iatrogenesis (cont.)

• 9/10 doctors fail to report adverse drug
  reactions side-effects of prescribed drugs
• Surgery carried out without clear evidence of its
  effectiveness

24
Social iatrogenesis

• Social iatrogenesis is a product of the medical
  organisation
• Professional dominance supports social
• iatrogenesis in order to reverse it, the state
  needs to intervene

25
Cultural iatrogenesis

• autonomy of people is restricted by medical
  behaviour of undermining lay knowledge and lay
  practice
• professionalisaton of medicine related to
  cultural iatrogenesis.

26
Problems with Illich

• Overstates his claims?
• What about the benefits of modern medicine?
• Proposes individual self help self reliance
• Is opposed to efforts to tackle social causes

27
? Is Illich still current........

• Moynihan, R and Smith, R (2002) Too
• much medicine? Almost certainly. BMJ,
• 324, 859-860 available free online.

28
Modern society Risk

• Societies characterised by fewer certainties
  lots of choice
• Risk is an inherent part of modern society
• Terrorism (food) ecological disaster nuclear
  war BSE (new kinds of risk)
• To what extent have we become over- sensitised to
  risk?
• (Giddens Modernity and Self Identity)

29
Modern society Risk (cont.)

• Increasing individualisation branding
• Need to make choices throughout life personal
  responsibility for successes/failures
• Life, death, gender, identity, religion,
  marriage, parenthood, social ties all coming
  down to individuals isolation if too
  fragmented social cohesion begins to disintegrate
• (Beck, U Beck-Gerneisham, (2002)
  Individualization p5)

30
Modern society Risk (cont.)

• Implications for health?
• Who has responsibility for health in modern
  society?
• What impact might risk society or constant
• choices have on
• - health status of individuals?
• - health policies?
• (See Beck, U (1992) Risk Society Beck, U
  Beck-Gernsheim, E (2002) Individualization)

31
Recent developments

• More emphasis on the social construction of
  medical knowledge
• New knowledge leads to new ways of viewing the
  body constructing disease
• Shift from hospital based medicine to
  surveillance in C20th
• Shift from location of disease within the body to
  the psycho-social links within body/communities
• Emphasis on lifestyle factors health promotion

32
Other developments

• Past drivers professional dominance,
  inter-professional rivalries, organisations/pressu
  re groups
• Present drivers biotechnology (pharmaceutical
  industry, genetics), consumers/consumerism,
  managed care markets (especially in USA)
• The important role of the media/internet

33
The challenges from changing patterns of disease

• More people are living increasingly complex
  diseases but these people are largely excluded
  from clinical trials
• A single patient may be taking 5 or more drugs,
  the combination of which has never been evaluated
• Chronic diseases require complex organisational
  interventions but how do we define and evaluate
  black box interventions in isolation from
  context?

34
The challenges of changing expectations

• Patients are no longer willing to accept being
  passive recipients
• Internet creating patient experts
• Yet risks from growing digital divide
• Potential problems faced by growing numbers of
  migrants (especially where they are illegal)

35
The shifting balance of care

• Treatment versus prevention
• Hospitals versus alternative settings
• Professional versus patient focus
• Evidence versus intuition
• Responding to demand versus
• responding to need

36
Alternatives to biomedical model

• health - a positive state of physical mental
  well being
• interventions aim to aid equilibrium, enhance
  bodys own healing capacities
• the patient is actively involved
• critical view of medical progress
• responsibility is individual and social

37
Investing in health Projections of future
expenditure on UK NHS under three scenarios

50 bn
Fully engaged major commitment to health
promotion/improvement
Source Wanless Report
38
Why welfare states do NOT reduce economic growth
- instead

• They adopt pro-growth policies
• emphasis on income consumption taxes, not
  taxes on capital
• income taxes designed to reduce marginal rates
  at top bottom
• welfare benefits encourage least productive to
  leave the workforce (early retirement,
  unemployment)
• they also encourage highly productive women with
  families into the workforce

Source Lindert 2002
39
Conclusions (i)

• Criticism can be made of both the orthodox
  medical and more recent sociological models both
  can be empire builders
• Need to be aware of different drivers of
  medicalisation over time, doctors role now
  subordinate in the expansion/contraction of
  medicalisation, biotechnology, consumers, managed
  care market now increasingly important

40
Conclusions (ii)

• A notable shift over recent years
• Illness (prevention) health (promotion)
• Lay beliefs lay knowledge
• Health is complex with its negative, functional
  positive dimensions varies by social position
  throughout life
• Lay expertise is an important dimension of the
  health promotion debate

41
Conclusions (iii)

• health policy - choices open to society
• collective individual levels of health,
• maintenance of good health,
• prevention of ill health,
• cure care of the sick disabled
• not just responsibility of health service
• medicine vs public health

42
Conclusions (iv)

• Challenges
• global health improvement
• unequal experience inequalities
• new diseases emerging
• ? ? costs of preventable illness/disability
• public health - whose responsibility?
• inequalities in health
• evaluate all policies for impact