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How Cartesian simplicity killed health

A research programme suitable for Honours, Research Masters, ILP and PhD students

DOI: 10.53714/ctci3377

The attainment of optimum health (a long life of most years without suffering from disease or affliction) and health equity (the opportunity for all to achieve fair optimum health levels) depends on achieving and maintaining systems of social choice (also known as governance and policy) that allow for just and proactive actions, maintenance and sustainable growth in social, political and commercial determinants of health. But what is health?

‘Health’ is generally recognised as a holistic notion. It is not the product of a particular intervention, but rather it is a state of being and a resource of everyday life for individuals, communities and ecosystems. Health is dynamic, relative and perceptual. This notion is reflected in contemporary definitions of health, such as WHO’s aspirational

…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

WHO

or Dubos’

…the expression of the extent to which the individual and the social body maintain in readiness the resources required to meet the exigencies of the future.

Dubos

Yet, the architecture and operations of what commonly is known as the ‘health system’ are not commensurate with such forward looking, integrated and joined-up views of the thing that most people around the world time and again rate as the highest good in life.

The health system, as many observers have noted, is in fact a disease care system, and its (sub)systems do not necessarily facilitate the attainment and sustainability of positive health (and health equity) in the community. Some of the more cynical scholars attribute this to the power and dominance of the clinical professions, others see interests of a ‘medical-industrial complex’ stand in the way of full health.

The disease care system does in fact exert unsurpassed dominance over local economies, professional development, and technological growth. Some estimates suggest that up to 99.9% of the budgets of public and private ‘health care’ systems go in fact to fixing disease, and less than 0.1% to the prevention of disease, and promotion of health and longevity. Even though sound arguments can be made that at many levels ‘prevention is better than cure’, this simply does not transpire into a redirection of political and social priorities.

Why would that be?

Speculation is rife. There are simplistic rhetorical devices that frame the issue as one of path dependencies between individual power and status, financial and other resource incentives, a neoliberal mindset in a neo-corporatist governance model, and avoidance of systems disruptors.

But is any of this true?

This programme of work aims to follow some phenomena/cases through time and space to map how health became the subject of a disease paradigm – and in the process lost its mojo. Understanding these pathways in many ways would allow us to more firmly ground CHETRE’s work on health and health equity among marginal populations, disadvantaged groups, challenged areas, and with people and systems that deserve our support and investment.

Evidence

When Archibald Cochrane published, in 1972, his frustrations about the poor foundations of medical practices in his tome “Effectiveness and Efficiency: Random Reflections on Health Services”, he was not arguing for an industrial-scale quasi-experimental conglomerate of heavy protocolised evidence generation networks. Rather, he recognised that ‘evidence’ for clinical practice was multi-faceted, dynamically evolving, and a matter between physicians and other healthcare professionals, and patients and their families (for good order sometimes regulated by public policy). Nearly fifty years later, the evidence generation industry has grown into a rather gargantuan global enterprise that is dominated by quantitative formulae and, at best, a protocolised involvement of ‘the consumer’. How did this come about? Who and what drove this process, to what purpose, and with what impact?

Translational and Behavioural Medicine

 There was a time when medicine concerned itself mainly with sick people, and social policy as well as sanitation engineers were concerned with maintaining health and preventing disease. But the seeds of colonial expansion of the discipline into other fields were always part of the enterprise. Whether it was Rudolph Virchow (‘‘Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution’’) or the 1910 Flexner Report effectively ‘othering’ health sciences out of medicine, the tension between clinical medicine and its ‘scientism’ on the one hand, and public health with a more socio-anthropological gaze on the other has been a permanent feature of the field. And rather than being content with the contributions other fields of inquiry and knowledge generation could make to ‘medicine’, the profession continues to expand its footprint. More recent colonisations include behavioural and translational medicine. The former seems concerned with the medicalisation of human health behaviour, the latter with bridging gaps between the traditional (clinically oriented) experimentation paradigms on the one hand, and social innovation and policy making on the other. Why and how is that happening? Why are social scientists and adepts of alternate knowledge systems drawn into a medical frame?

Implementation science and knowledge translation

Newer branches of the above two developments include novel disciplinary innovations such as ‘implementation science’ and ‘knowledge translation’. Outside the clinical, medical domains questions of implementation and knowledge use had been raised with a comforting stanza. In particular in philosophy, sociology and science and technology studies the emergence of knowledge in its many forms, and how it may or may not change social practice has been subject of intense study. The names of Foucault and Bourdieu come to mind in the more philosophical analyses, Latour, Callon and Mol looking at the in/pervasion of changing knowledge into social, political and industry systems, and Sabatier, Howlett and Cairney in political and administrative perspectives on policy change and stability. But none of this seems to have mattered much to the hegemony of medical science, as (a) the connections between these fields and medicine have remained tentative and often problematic, and (b) in retaliation (or desperation?) medical disciplinarians started to offer their own alternate world views to the approaches of philosophers, science & tech researchers, and political scientists. Why did that happen? What strategies were deployed? By whom? With what effect?

(public)(health)(care)(policy)

A quick scan review of the content of the authoritative peer reviewed journal Health Policy (IF 2.98) indicates that the journal publishes neither on ‘health’ nor on ‘policy’ in any impressive manner. Rather, ‘Health Policy’ seems to be equivalent to health services research, healthcare protocol assessment, disease treatment efficiencies, and disease management operations. Out of the 5,634 papers published since its inception, only 6 seem interested in policy for health – rather than the remaining 5,628 that focus on disease or infirmity (I used ‘HiAP’ and ‘health promotion’ as proxy search terms to arrive at this assertion). It seems there is more glory, recognition, status and ‘publishability’ in disease, infirmity, disability, misery and despair. Is this true? If so, why, when, how and driven by whom and what?

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