It would seem obvious, when looking at a model for a health care system, to consider health. However, medical training until now has tended to focus on pathologies and its treatments rather than on health.

The World Health Organisation has defined health as:

Not the mere absence of symptoms or infirmities but a state of physical, psychological, spiritual and social well-being.

In the public health sector, much thought and action is influenced by this definition but in the practice of medicine it seems to remain a theoretical concept. The daily work of doctors is dominated by finding a diagnosis for the presenting symptoms and taking measures to treat the condition. While the aim is essentially to reduce suffering, and is therefore commendable, it is the experience of many doctors that the system is not as effective as it should be. Often patients’ symptoms may clear up, but are replaced by other symptoms, sooner or later. Then the doctor is challenged to go on handing out more drugs, often quite a cocktail, not knowing what else to do. In cases of long-term chronic illness this approach can become particularly disheartening. All doctors know ‘heart sink’ patients whom they dread to see – yet again – as they feel unable to offer any significant help and this is stressful and demoralising.

Medical practice can become much lighter and more inspiring if the focus turns to health, wellness and life quality. Stress management, lifestyle changes, improved social interactions, insight into behavioural or emotional patterns which aggravate or maintain the illness and, above all, increased self-care can all make a tremendous difference to patients’ lives. With these tools used as an integrated approach to health care, all patients can be supported, no matter how severely ill or chronically debilitated they are, to improve their life quality. Doctors can then feel their contribution as valid and real, while patients feel empowered and in charge of their health care.

To implement such an integration, the shift has to take place from a disease-centred approach to a health-focused approach to health care. In addition to studying pathology, medical students need to study that which constitutes health, so they can
measure people’s present situation and assess their progress as time goes by. Health is less easy to define than illness, but it is more than absence of symptoms.

Working Definitions of Health

Many attempts have been made to define a yardstick of optimum health. The challenge is that health cannot be defined by objective standards but rather through subjective experiences and processes. This is reflected in the following definitions.

We are coming to understand health not as the absence of disease, but rather the process by which individuals maintain their sense of coherence (i.e., sense that life is comprehensible, manageable, and meaningful) and ability to function in the face of changes in themselves and their relationship with their environment.[1]

In the first half of the twentieth century there was an inspiring research project into factors which foster health, called the Peckham Experiment. It resulted in some guidelines which can be summed up as:

Health is the ability to respond to all life situations in a way that increases capability, responsibility, autonomy, spontaneity and joy.

These definitions acknowledge that changes and challenges in life have an essential role in human development as they potentially increase skills and expertise, as well as broadening a person’s world view. Capability expands, for instance, when constructive coping mechanisms or self-care skills are learned. Autonomy results from increased self-awareness and self-esteem finding the strength within to utilise available resources. With a widened awareness of health and the interconnectedness of their well-being with that of others and their surroundings, people assume more responsibility for their own lives and take on a more responsible role in striving for the integrity of society and the natural environment. Spontaneity comes with the freedom and empowerment of people taking full responsibility and trusting their own capabilities. All this leads to the appreciation of the role they can play in the world. Joy comes from many things, small and big, especially when people are in touch with their own strength and the beauty and perfection all around them.

The value of these definitions of health is that they give specific qualities which can be observed by the health care practitioner as well as by the patient. They make it possible to assess the degree of health present and to decide which strategy can move the patient towards greater health. The question can be asked: will this particular step/treatment/intervention increase the sense of coherence and ability to function of the patient? Will it expand the person’s capability, spontaneity and joy?

These definitions can also be applied in situations of chronic illness. Someone can be intensely physically ill, with cancer for example, yet if their spirit is soaring and they are taking steps to assist humanity’s progress, then they are dealing with life in a most healthy and creative way. It can even apply to the last stage of life – death –  for at a certain point in each person’s life, the healthiest option is to die.

An important aspect which must not be overlooked is that health is a process, a dynamic rather than an absolute state.

Health is not a static condition achieved once and for all, but a dynamic on-going process of change. It is interwoven with all the elements of well-being, and depends on the integration of physical, emotional and spiritual levels of consciousness.[2]

If health becomes a standardised norm, it is never achievable and leads to a tyranny of health much like the tyranny of youth – an ideal which is always out of reach. As people are all different from one another, applying any norm is disrespectful of their individual expression. This has been seen in the tyranny of the ‘perfect body’, which has led directly to society’s collusion with conditions such as anorexia or bulimia. This can be illustrated in the case of a young woman who had been a stocky teenager. She lost a lot of weight in her twenties which led to severe health problems, including gastro-intestinal ulcers, amenorrhoea and immune deficiencies. For two years she presented symptoms bordering on anorexia. She eventually recovered her health with the help of various complementary therapists who enabled her to recognise the pathological patterns she had been exhibiting. Now in her thirties, she condemns the social sanctioning and the praise – even from her family and close friends – which she received for being fashionably thin, when in fact she was destroying her health and well-being.

Health therefore has to be tailored to the individual. Life quality is more relevant than absence of symptoms or longevity. The quality of each interaction, including that of the caring relationship, is where health is being expressed and experienced moment by moment.

The ‘Health Doctor’

In implementing a positive definition of health, health care professionals are able to shift their attention from disease care to health-focused care. The expansion of health becomes the objective – the reduction or cure of symptoms are almost incidental.

In this scenario, they have the opportunity to become ‘health doctors’ which requires different skills and brings with it its own rewards. Health doctors will provide services to benefit people in all different situations in life. They can give:

  •  nutritional advice;
  •  help create strategies for active living which provide exercise in the daily routines;
  •  offer stress management skills;
  •  advice on child rearing;
  • guidance on relationship challenges and so on.

The recommendations they make to their patients on positive living may include:

  •  taking up a hobby which provides physical activity and social interaction;
  •  attending a yoga class;
  •  learning a new style of cooking;
  •  expanding the range of healthy options when shopping for food;
  •  entering an evening class for intellectual stimulation or expanding career options;
  • having regular bodywork sessions to deal with stress-related physical tensions;
  • exploring new ways of expressing creativity;
  • engaging in counselling to release old patterns of limiting interaction and improve communication skills with partners or children.

The Health Overhaul

Health doctors will recommend that their patients have a regular annual ‘health overhaul’ to review the present state of health on all different levels, to confirm what works well and to introduce new goals of health enhancement. A possible format for the health overhaul is for the patient to fill in an extensive questionnaire covering all medical information, family history, social background, lifestyle, and the functioning of their different physical organs or systems. Before any future overhaul they will reflect on any changes which have occurred, and use a shorter questionnaire to assess their present situation. In the consultation, apart from the physical examination and some laboratory tests, the doctor and patient will reflect together on the following areas: diet; exercise; emotional, social, spiritual and work life; and creativity, as well as family and intimate relationships. Future goals are discussed and concrete steps towards achieving them agreed.

Health overhauls are particularly relevant at specific crossroads in life:

  •  preconception
  • antenatal
  • early childhood
  • weaning
  • entering school
  • puberty
  • family planning
  • menopause/middle age
  • retirement and old age

These particular stages are opportunities to evolve and monitor strategies for health enhancement in an individual’s life.

The relationship between the health doctor and the patient takes the best from the old-fashioned family doctor who knew everyone in the extended family and could provide care from birth to death bed. Family doctors were companions on their patients’ life paths, advisers to be at hand when their expertise was required. However, the new health doctors will not be ‘experts’ who disempower patients but partners interested in empowering patients to take increasing responsibility for their lives.

Moves in the Right Direction

While fully embracing a holistic attitude towards disease may be some way distant for much of the medical profession, steps have been made for some time towards expanding medicine beyond disease care. Vaccination programmes, which are promoted by the NHS, are an example of an attempt at disease prevention rather than cure. Screening programmes for cancer are not preventative as such, but may enable disease to be detected and treated earlier, which potentially increases the chances for a better outcome. Health promotion educates the public and has been shown to contribute to increased general awareness.[3] Health protection includes legal measures, regulations, health policies and voluntary codes of practice used in the workplace to stop people from being harmed.

But while health care today may be increasing its focus on these preventative and educational measures, the concept of health enhancement is still missing. One of the motivating factors which may lead the NHS towards adopting the major shift in emphasis that is needed, is desperation to find a way of reducing the ever spiralling cost of health care.

Health Enhancement

Health enhancement is the care that is relevant in everyone’s daily life. No matter what people’s current state of health, there is always some measure that can be taken that will increase their quality of life. This applies as much to the chronically ill as to those who are blessed with physical fitness and a strong constitution. Health enhancement requires education which goes much further than that which is currently on offer. It provides the individual with information and basic skills such as nutritional awareness, dealing with emotions, social and communication skills and stress management. The health doctor’s primary role is the fostering of empowerment and motivation for self-care.

Currently health education has achieved general public awareness of health hazards, such as smoking and alcohol and the links between diet, exercise and common disease. However, studies have shown that this knowledge is not matched by action.[4]

Choosing health is still not a high priority in our society – neither for individuals nor for the collective.

What will allow healthy choices to become easy choices? An individual needs motivation, positive reinforcement and inspiring examples. The Peckham Experiment demonstrated some of the resources which facilitate the nurturing of health:

The health doctor, just like the sickness doctor, needs tools, but they are of a very different kind – the gymnasium, the swimming pool, the cafeteria and so on. It is natural that the instruments for health should be varied because health covers a very wide field and includes physical, mental, social and even economic life.[5]

The participants in the Peckham Experiment found company in their striving for health and well-being. Social norms were formed which sanctioned and reinforced positive healthy choices.

Strategies for Implementing Positive Health Care

Too often health gets taken for granted until it fails. Illness calls attention to the precious nature of health and spurs the commitment to foster and nurture it. It is in this situation that a practitioner focusing on health enhancement can make a great difference. With a ‘captive audience’ the disease care necessary is provided for relief or cure and then the issue of health restoration and maintenance can be addressed. Patients are often grateful to hear what they can do to ensure that illness does not recur. This is an opportunity to instigate changes in attitude and behaviour in a sustainable way. The health care professional then becomes the companion and resource of information and support for health enhancement. This way practitioner and patient become partners in positive health care.

The following points are important in applying this ideal:

  • focusing on the areas of strength;
  • determining small manageable next steps;
  • monitoring progress and offering ongoing encouragement.

Focusing on the areas of good health and affirming patients in what they are already doing well is a cornerstone of the partnership. It is important to find out where their strengths lie, whether it is a good exercise routine, a sensible diet, positive relationships or a strong spiritual connection. This may require detective work on the part of the doctor, as many people take for granted their strengths and only mention their difficulties. However, affirming a person’s strengths and encouraging them to take pride in what they are doing well is a strong foundation for further progress.

From these points of strength, options can be explored to find small, manageable steps leading to improved health, which can be sustained on a long-term basis. This may be a change in diet from using refined carbohydrates to using whole foods. If, for example, a person who uses a lot of refined produce starts to use brown rice instead of white, their health gain may be considerable as long as they manage to sustain that change and expand on it. Similarly someone who decides to cycle to work instead of driving may experience increased sensations of well-being over a period of time. Aspirations for dramatic changes are not encouraged, as experience shows that high ideals may not be achieved and the benefit of good intention is lost. Potential damage may be done as people become less confident in their ability to change or even become cynical about healthy choices.

Monitoring the progress is crucial, as individuals need a point of review and continuing support. Without this the intentions may well be smothered by daily routines and the all too common resistance to change. These points of review are also an opportunity to continue education and broaden the options for healthy choices. This ongoing relationship with the ‘health doctor’ ensures that the changes can be sustained and expanded upon. For the patient this becomes a success story of ever increasing self-empowerment, confidence and improved life quality. For the health care practitioner it is the guarantee of high job satisfaction.

The Economics of Health Enhancement

Remuneration for service makes health care professionals reliant on ill health for income. A built-in conflict of interest may prevent them from working to make themselves redundant.

In the old Chinese system, doctors were only paid by those individuals in their community who they had enabled to remain healthy. This ensured that they were mainly preoccupied with health care rather than disease care. The National Health Service in Britain in its purest essence is not that different, as the tax payers contribute only as long as they are fit enough to work. However, contributions to National Insurance are so far removed from the contributor, as well as from the health care provider, that the immediacy and therefore the power of the Chinese tradition is lost. The greatest power lies in the relationship between the individual who makes the payment and the attending health care professional. For people to invest in their own health – by paying for it – is often a crucial part of taking responsibility for their own care. This is the argument for private health care, as it empowers patients and puts them in charge of the contract with the health care professional. Private health care may be a solution in an affluent society, as a health enhancement contract, but for disease care in a society where there are people who would not be able to afford appropriate care, it is a source of social injustice and deprivation. For this reason it cannot be advocated even though the education and self-empowerment value of it is considerable.

A system needs to be developed which will provide the best of both worlds:

  • the necessary care provision free at the point of delivery;
  •  the immediacy and empowerment of a private contribution or subscription scheme

In an intentional community with a population of 500, an experimental private subscription scheme was implemented and surveyed after three years. Even though it was a middle class, affluent community with a theoretical knowledge of health
issues, less than 20% of the population joined the scheme and the main usage of the services provided was when health failed.[6] This demonstrates what an enormous effort it will take to shift general consciousness from disease care to health care. This is a task truly deserving of considerable and concerted effort for the next century.

References:

  1. A Antonovsky, Unravelling the Mystery of Health: How People Manage Stress and Stay Well, Jossey-Brass, 1987.
  2. Diana Whitmore, Psychosynthesis Counselling in Action, Sage, 1994.
  3. Highland Health Board, Lifestyle survey 1991 – agenda for action, Inverness, 1991.
  4. ibid.
  5. Lucy Crocker, The Peckham Experiment, Scottish Academy Press, 1985.
  6. David Ponka, A survey of attitudes towards health and the Community Health Scheme within the Findhorn Foundation Community, Findhorn, 1996.

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This post was previously published as a chapter in the book Medical Marriage, the New Partnership Between Orthodox and Complementary Medicine, Dr Cornelia Featherstone and Lori Forsyth, published by Findhorn Press, 1997.