For U.S. health care, some are more equal than others

death-rate-after-surgeryThe Affordable Care Act (ACA, aka Obamacare) will expand insurance coverage to millions of Americans (for example, to individuals with pre-existing conditions). Having insurance, however, does not mean a primary care physician will be willing to take you on as a new patient. There are multiple reasons for this, as discussed in a recent article in JAMA, Implications of new insurance coverage for access to care, cost-sharing, and reimbursement (paywall).

We no longer live in the Marcus Welby days of a medical practice that has only one or two doctors. The “vast majority” of primary care practices, however, have only 11 or fewer physicians (according to JAMA). Many of these practices are already at or near capacity, which means that adding new patients may require additional expenses (staff, office space, equipment). For small practices, the decision to add new patients is first and foremost a business decision: Will the increased income cover my increased expense? Here are some of the things the “vast majority” of providers will be thinking about:

  • The ACA lowers the cost of health insurance for many individuals, in particular, for people with relatively low incomes. These patients, however, will pay more for health care itself due to higher co-pays (that part of the cost not covered by insurance) and higher deductibles (the maximum annual out-of-pocket expense). In the past, the main burden of collecting fees was on insurance companies. Under the ACA, it may be health care providers who are faced with a “collection burden.”
  • Read more

Share

When healthy eating becomes unhealthy

healthy-eating-orthorexiaMeghan O’Rourke, poet and author (Halflife: Poems, Once: Poems, The Long Goodbye: A Year of Grieving), has written a wonderful piece for The New Yorker on living with a chronic illness. It’s called What’s Wrong with Me? I had an autoimmune disease. Then the disease had me.

For years O’Rourke experienced symptoms that she tried to attribute to her latest source of stress. Doctors were unable to offer a diagnosis, a situation that tends to suggest the suspicion that the symptoms may be all in your head.

She writes: “I was ill for a long time — at least half a dozen years – before any doctor I saw believed I had a disease.” Eventually, after she received a label for her symptoms (autoimmune thyroiditis or Hashimoto’s disease), she connected to the online community of chronic disease sufferers. There she found not only a great many individuals with similarly frustrating histories, but an abundance of home-grown advice for the relief of symptoms.

A more or less definitive diagnosis for a disease that is only vaguely understood may at least confer some legitimacy on one’s status as a patient (for an historical perspective on diseases that do not fall neatly into diagnostic categories, see Robert Aronowitz, Making Sense of Illness .) The individuals who suffer, however, are still very much on their own when it comes to recovery and the alleviation of symptoms. Thus the home-grown advice.

Orthorexia and healthism

What I’d like to focus on in this post is one small part of O’Rourke’s narrative: her attempts to alleviate her symptoms through a growing obsession with the selection and control of the food she ate. It’s not difficult to find media stories and blog posts that put a positive spin on (what amounts to) an excessive preoccupation with healthy eating. It’s rare, however, to find an experiential account that recognizes the obsessive pursuit of health as itself unhealthy.

A classic discussion of the latter is Steven Bratman’s Health Food Junkies: Orthorexia Nervosa – the Health Food Eating Disorder. In O’Rourke’s case, of course, she was not simply eating to be healthy. She was seeking relief from very real and disturbing symptoms. That’s not quite the same thing as orthorexia, although both provide the health food consumer with an opportunity for reflection.Read more

Share

Neoliberalism, tobacco, and public health (2)

The occasion for the rambling reflections on neoliberalism in the previous post was three “perspective” articles on tobacco in a recent issue of The New England Journal of Medicine. Two of them concern the FDA’s attempt to place graphic warnings on cigarette packs. The other is on cigarette smoking among the homeless.

The First Amendment

fda-graphic-warning-labels-cigarettes-are-addictivePlacing graphic warnings on cigarette packs was part of the 2009 Family Smoking Prevention and Tobacco Control Act. The tobacco industry sued the FDA (R.J. Reynolds Tobacco Co. v. FDA), claiming the warnings violated the industry’s First Amendment rights. In a case decided last year, the tobacco industry won.

David Orentlicher, in his article The FDA’s Graphic Tobacco Warnings and the First Amendment, writes that the decision is both surprising and not surprising. It’s not surprising “given the Supreme Court’s increased sympathy toward corporations and their First Amendment rights. Regulations of commercial speech often succumb to judicial scrutiny.” It’s surprising because, while the Supreme Court now restricts the government’s power to regulate corporate speech, it has not in the past interfered with the government’s authority when it comes to regulating matters of public health. Evidently, that’s not the case anymore.

The upshot: (emphasis added)

[C]ompanies today are better able to promote their products, and government is less able to promote health than was the case in the past. Ironically, early protection of commercial speech rested in large part on the need to serve consumers’ welfare. In 1976, for example, the Supreme Court struck down a Virginia law that prevented pharmacists from advertising their prices for prescription drugs. The law especially hurt persons of limited means, who were not able to shop around and therefore might not be able to afford their medicines. Today, by contrast, courts are using the First Amendment to the detriment of consumers’ welfare, by invalidating laws that would protect the public health.

Read more

Share

Neoliberalism, tobacco, and public health (1)

This post became much too long, so I’ve divided it into two parts. The first part is mainly about neoliberalism; the second mainly about graphic warnings on cigarette packs (plus smoking among the homeless). When I read, in a recent NEJM article, “The Supreme Court’s increasing sympathy for corporate speech and decreasing deference to public health authorities makes it more difficult for government to protect the public’s health,” my first thought was: What a perfect example of neoliberalism in action.

fda-graphic-warning-labels-i-cause-diseaseNo one would claim that neoliberalism strives for consistency when implementing its ideals. For example, neoliberalism blames individuals for the health consequences of cigarette smoking (“I cause disease”) and at the same time opposes legislation to reduce cigarette consumption (graphic warnings on cigarette packs). When there is a choice to be made, the deciding factor for neoliberalism will be the efficiency with which wealth can be upwardly redistributed.

Personal responsibility

Personal responsibility — including personal responsibility for health — is a fundamental principle of neoliberalism. David Harvey writes on this in the context of neoliberalism and labor: (emphasis added in this and subsequent quotations from Harvey)

[L]abour control and maintenance of a high rate of labour exploitation have been central to neoliberalization all along. The restoration or formation of [elite] class power occurs, as always, at the expense of labour.

It is precisely in such a context of diminished personal resources derived from the job market that the neoliberal determination to transfer all responsibility for well-being back to the individual has doubly deleterious effects. As the state withdraws from welfare provision and diminishes its role in arenas such as health care, public education, and social services, which were once so fundamental to embedded liberalism, it leaves larger and larger segments of the population exposed to impoverishment. The social safety net is reduced to a bare minimum in favour of a system that emphasizes personal responsibility. Personal failure is generally attributed to personal failings, and the victim is all too often blamed.

Personal responsibility for health — fundamental to healthism (a frequent topic on this blog) — serves the interests of neoliberalism in a number of ways. It can be used to justify reduced spending on health care and social services by the state. This is desirable in itself, according to neoliberals, but it also increases consumer spending on health care, which in turn benefits the health care, pharmaceutical, and insurance industries.Read more

Share

The general health checkup: Its origins, its future

What is a general health checkup? It’s when you visit a doctor not because of an ongoing chronic condition or because you’re concerned about new, unexplained physical or mental symptoms, but because you want a general evaluation of your health. The assumption behind such a visit is that if you do this regularly, you may prevent a future illness.

general-health-checkups

A recent issue of JAMA had two articles on general health checkups. One of them asked the question: What are the benefits and harms of general health checks for adult populations? It summarized a 2012 Cochrane review that addresses this question (it was written by three of the four authors of that review). The review concluded that health checkups were not correlated with fewer deaths (reduced mortality), neither deaths from all causes nor from cancer or cardiovascular disease in particular. Health checkups were associated with more diagnoses, more drug treatments, and possible (but probably infrequent) harm from unnecessary testing, treatment, and labeling.Read more

Share

Two children visit their doctors: Social class in the USA

Rick Santorum, responding to Obama’s statement that “the middle class in America has really taken it on the chin,” said that he would never, ever, stoop to using the word “class.” (Dorothy Wickenden in The New Yorker)

Sociologist Annette Lareau has done extensive field work that involves unobtrusively inserting herself (or her field-worker assistants) into the homes and daily lives of families (treat us like “the family dog,” she recommends). Her observations have led her to identify a difference in the parenting styles of families from different social classes. Middle-class families practice what she calls concerted cultivation: parents teach their children skills that prepare them to engage successfully with the social institutions of adult, middle-class life. Working class families value natural growth: parents give their children a great deal of unstructured time in which they must use their own creativity to plan and execute their activities.

rich-poor-children-social-inequality

Lareau’s work is described in her book Unequal Childhoods: Class, Race, and Family Life. Originally published in 2003, it was updated for a 2011 edition. It’s a wonderful book. I think of it whenever people argue – as they frequently do in the US – that America is the land of equal opportunity, therefore those who fail to exert themselves sufficiently have only themselves to blame.

I’d like to cite two stories from Lareau’s book that relate to health care.Read more

Share

What pediatrics can teach us about addressing adult social determinants of health

patient-centered-medical-homeAttending to the social determinants of health is especially important for children, since children’s experiences – of poverty, poor nutrition, trauma, abuse, neglect, the prenatal environment – can affect physical and mental health for an entire lifetime. As the authors of a recent commentary in JAMA write: “Pediatrics … continues to evolve clinical practice aimed at addressing social determinants because of children’s exquisite vulnerability to the deleterious effects of the social and physical environment, especially the aggregation of social factors associated with poverty.”

The occasion for the commentary – titled Addressing the Social Determinants of Health Within the Patient-Centered Medical Home: Lessons From Pediatrics — is the imminent implementation of the Affordable Care Act. The medical home (also known as the patient-centered medical home) is a concept that originated in pediatrics. The basic idea is that when a team of providers — physicians, nurses, nutritionists, pharmacists, social workers – work together, they can best meet the needs of patients. The Affordable Care Act has several provisions designed to establish and promote medical homes, and the authors of this commentary (two pediatricians and a family medicine practitioner) ask: What has pediatrics learned about addressing social determinants that can be translated to medical homes for adults.Read more

Share

A new blog on the self

new-blog-kittenI’ve started another blog called Basic research on the self. My intention is to write there about the social and cultural history of the self, aided by insights from sociology, anthropology, philosophy and psychology (especially critical psychology). This is a subject that relates to a number of topics I’ve written about here.

A while back I grouped together my interest in psychopharmaceuticals, cosmetic surgery, happiness/positive psychology, and self-help and labeled these topics “psychological and physical conformity.” When I’ve written about these subjects, I’ve talked about the way things are today. In my new blog, I’d like to step back and ask: How did the society I live in end up valuing self-actualization, self-improvement, and maximized happiness – as well as an impossibly ideal notion of physical appearance — above all else?

That question also relates to a number of my other interests here — healthism, the social determinants of health, inequality, neoliberalism. It’s much easier to convince people they’re personally responsible for their health and well-being (including their socioeconomic status) if they’ve already developed a self-concept based on the ideology of the self-contained, autonomous individual.Read more

Share

A culture of health needs a market for health

Determinants of healthThis feels encouraging: Two Viewpoint articles in a recent issue of JAMA (The Journal of the American Medical Association) on improving population health (both behind a paywall, unfortunately).

Population health

What is population health? Apparently it depends on who you ask. If you ask those with a financial stake in the health care delivery system, population health means improving the health of patients who currently use (i.e., pay for) the system. You get a different answer if you ask those involved in public health, community development, or social services. They believe “population” should include everyone in the entire geographic community, whether or not those individuals are able to use or benefit from health care services. They also believe “health” should include quality of life and economic well-being – measures that prevent disease in the first place – and not just conditions addressed by the medical model of disease.

What I especially liked about Stephen Shortell’s article – Bridging the Divide between Health and Health Care – was its economic realism. I dearly wish that those with a financial interest in the health care industry, as well as politicians who control health policy, would acknowledge that the way to improve health is to address its social determinants. But trying to change the hearts and minds of stakeholders is like pushing against the tide.Read more

Share

Healthy lifestyles: Social class. A precarious optimism

Social determinants of health. Marmot, WilkinsonContinued from the previous post, where I noted that the Lalonde report — despite its good intentions — was followed by an emphasis on healthy lifestyles and personal responsibility for health, as well as increased health care costs.

Personal responsibility and social class

In Why Are Some People Healthy and Others Not?, Marmor et al, writing in 1994, were disappointed that the Lalonde report had not effectively prompted governments to address the underlying causes of health and disease. One reason for this, they believed, was that health policy reflects public opinion. If the public holds traditional views on what makes us sick (pathogens), what prevents disease (medical care), and what we can do to be healthy (take personal responsibility), new policies that include social determinants are unlikely. Those who are on the forefront of professional, scientific opinion may very well understand the importance of social determinants, but public opinion changes slowly. Without an education program, such as the relatively successful anti-smoking campaign, the public is unlikely to endorse change.

This is certainly true, although I believe there’s also something more fundamental at work here, namely, how a society accounts for the different life outcomes of its citizens. In Unequal Childhoods: Class, Race, and Family Life, Annette Lareau describes the assumptions people make when they hold others personally responsible for their life circumstances.Read more

Share

Healthy lifestyles: The unfortunate consequences

Healthy lifestyles yoga poseContinued from the previous post, where I discussed the expansion of universal health care prior to the 1970s, how this created a growing demand for health care, and the problem health care costs posed for governments, especially when the economy suffered a downturn in the seventies. One response to the situation was to consider new ideas. Rather than limit strategies to what could be done by the health care industry, why not directly address the underlying causes of disease by considering social determinants of health.

Canada’s Lalonde report

In 1974, Canada produced the Lalonde report. It has been described as

[the] first modern government document in the Western world to acknowledge that our emphasis upon a biomedical health care system is wrong, and that we need to look beyond the traditional health care (sick care) system if we wish to improve the health of the public.

The US Congress emulated this thinking in 1976 by creating the Office of Prevention and Health Promotion. The US Department of Health, Education, and Welfare began publishing the document Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention in 1979. The response in European countries — caught in the same bind of greater demand, increasing costs, and the financial consequences of a deteriorating economic landscape – was similar.

The common thread in these new perspectives on health was the assertion that health could be improved — without increasing health care costs — if we concentrated on such things as the work environment (occupational health), the physical environment (air and water pollution, pesticides and other carcinogens in food), genetics, and healthy lifestyles. The approach was broad: the environment was considered at least as important as the promotion of healthy lifestyles.Read more

Share

Healthy lifestyles: The antecedents

Healthy lifestyles yoga poseIn the 1970s, public health policies began to promote the idea that individuals are responsible for their health and therefore have an obligation to adopt healthy lifestyles. Over the ensuing decades, health became both an extremely popular topic for media coverage and a lucrative market for vendors of health-related products and services. What followed was a substantial increase in health consciousness and greater anxiety about all things that concern the body.

Do healthy lifestyles actually produce better health? That they should may seem like common sense, which is one reason it’s been so easy to promote the idea that they do. The question is difficult to answer with absolute certainty, however. For one thing, the behavior that counts towards a healthy lifestyle does not readily lend itself to the objective measurements required for reliable scientific evidence. Defining health is also tricky. Lifespan is often used to compare the ‘health’ of different nations, but this fails to capture the subjective sense of health that is meaningful to individuals. Perhaps most important, while in theory a healthy lifestyle might improve health, that does little good if – as is now obvious – it’s extremely difficult to maintain behaviors that require things like changing what we eat and how often we exercise.

A related question would be: Did the promotion of healthy lifestyles reduce health care costs? This too seems like a sensible assumption, and the assertion is quite popular, especially among politicians. Health care costs have increased to hand-wringing levels. Promoting healthy lifestyles costs governments next to nothing, while the cost of health care is all too easily quantified.Read more

Share

A more equitable future? US reveals its true intentions

Occupy Wall Street: Light at the end of the tunnelWhy is it so hard to convince policy makers worldwide to address the social determinants of health, including poverty, hunger, and income inequality? Judging by the excerpt below, we shouldn’t count on the US to champion this cause any time soon. It’s from a document called “The Future We Want,” issued by the Rio+20 conference last June. The US requested changes to the document, indicated in bold (additions) and strike-outs (deletions).

Eradicating poverty is the greatest global challenge facing the world today and an indispensable requirement for sustainable development. In this regard we are committed to free humanity from extreme poverty and hunger as a matter of urgency.

We recognize that promoting universal access to social services can make an important contribution to consolidating and achieving development gains.

We strongly encourage initiatives at all levels aimed at providing enhancing social protection for all people.Read more

Share

Profit-driven medicine: Satisfying patients at the expense of their health


Why would patients who report greater satisfaction with their health care be worse off medically? This JAMA article, Patient Satisfaction & Patient-Centered Care: Necessary but Not Equal, offers an explanation that makes sense. It points to the commercialization of health care – treating the patient as a consumer – as the villain. (All quotations in what follows are from this article.)

The patient (consumer) satisfaction survey

In the US, many doctors are evaluated and rewarded based on patient satisfaction surveys. Motivated to produce high patient satisfaction scores, doctors are inclined to order more diagnostic tests. Why? It’s more than a simple desire to please the patient.

When physicians’ performance evaluations and incomes are tied to patient satisfaction, the situation becomes ripe for overuse and misuse of diagnostic and therapeutic procedures because it allows the physician to rationalize decision making in terms of patient satisfaction.

Pleasing a patient is a conscious, individualized choice. Rationalized decision making can easily become an automatic habit that requires no additional thought.Read more

Share

On healthism, the social determinants of health, conformity, & embracing the abnormal: (4) The abnormal part

Abnormal psychologyContinued from parts one, two, and three.

A year ago, when I decided to call my declining rate of blogging a ‘sabbatical,’ I wrote down some questions to explore while I took time off to read.

How did we find our way into the dissatisfactions of the present – the commercialization of medicine, the corporatization of health care, the commodification of health? Does understanding the path we followed offer any insight into finding a better direction? Was the increasingly impersonal nature of the doctor-patient relationship inevitable once medicine became a science? Or was it only inevitable once health care emphasized profits over patients and the common good?

At the time I thought I would read primarily in the history of medicine, and that was how I started. Appreciating the historical context of medicine is important for understanding both how medicine ended up where it is today and what medicine could become. “The texture and context of the medical past provide perspective, allowing us to formulate questions about what we can realistically and ideally expect from medicine in our own time,” I wrote.

Now that I’ve become more familiar with the social determinants of health, I’m less optimistic about the future. The problem is not simply that the corporatization of health care has increased dissatisfaction among both doctors and patients. The problem is that our focus is so narrowly limited to health care systems that we fail to see the larger issue. As one metaphor puts it, doctors are so busy pulling diseased patients out of the river, there’s no time to look upstream and ask who’s throwing the bodies into the water.Read more

Share

On healthism, the social determinants of health, conformity, & embracing the abnormal: (3) Connections

Continued from parts one and two, where I defined the terms used in the following diagram of my blogging interests. Click on the graphic for a larger image.

Blog topics and their connections

If I had written the previous two posts a year ago, I would have realized how much my interests were intertwined. I guess I wasn’t ready to do that. Anyway, in this post I catalog some of the connections.

Healthism

~ Healthism and psychological and physical conformity: Healthy lifestyle campaigns promote an ideal way of life that encourages individuals to alter their behavior and appearance. Although it’s true that we would all be better off if we didn’t smoke, that doesn’t make anti-smoking laws any less authoritarian, i.e., requiring conformity (see the section on anti-authority healthism in this post). The fitness aspect of healthy lifestyles promotes the desirability for both men and women of acquiring (i.e., conforming to) specific body images.

“Self-help is the psychiatric equivalent of healthism.” That’s a slogan I made up. I’m not sure yet if it will stand up to scrutiny. Certainly the self-help industry encourages self-criticism, which leads to a preoccupation with those aspects of personality currently considered undesirable.Read more

Share

On healthism, the social determinants of health, conformity, & embracing the abnormal: (2) Economics & the socio-political

Continued from part one, where I discussed the first three of my six interests: healthism, medicalization, and psychological and physical conformity. Click on the graphic below to see a larger image.

Blog topics and their connections

The social determinants of health

Social determinants of health (often abbreviated SDOH) refers to unequally distributed social and economic conditions that correlate with unequal and inequitable distributions of health and disease. Presumably there is a causal relationship between the two, not merely a correlation. Definitively identifying the causal mechanisms, however, is difficult. A great many things influence our health (including things we’re not even aware of yet), and it can be difficult to isolate and scientifically study some of the ones we strongly suspect, like poverty, isolation, or a sense of being socially inferior.

The medical model is the preferred framework in modern westernized societies for explaining the distribution of health and disease. It emphasizes risk behavior (smoking, diet), clinical risk factors (blood pressure, blood sugar, cholesterol levels), genetics, health care access and quality, behavioral change, and patient education. One common characteristic of the medical model’s explanation of health and disease is that causes are located in the individual (behavior, genes), not in the individual’s economic and social environment.Read more

Share

On healthism, the social determinants of health, conformity, & embracing the abnormal: (1) Bodies, minds & medicine

It’s always hard to be sure about these things, but I think the reason I decided to take a ‘sabbatical’ from blogging last July was that I was interested in too many seemingly unrelated topics. Writing about all of them left me feeling like I never got to the ‘meat’ of any one of them. And I couldn’t convince myself to focus on just one or two things, since that would mean abandoning the others, which I was unwilling to do.

Now that I’ve taken the past year to read and reflect, I find – duh! – that my interests are not as unrelated as I’d assumed. In hindsight, I should have realized this long ago, but, alas, I did not. I’m writing this post to clarify to myself what I now see as the common threads that connect my interests.

Here is a diagram that groups my interests into six categories. (Click on the graphic to see a larger image.)

Blog topics and their connections

Four of the six categories relate to all five of the others. The two outliers (neoliberalism and medicalization) are not as directly related as I feel the others are.Read more

Share

Guest post: The unemployed as the waste products of the success factory

Waste products of the success factoryPierre Fraser is an author, essayist, and PhD candidate in sociology at Université Laval. We share an abiding interest in healthism or, as Pierre would say, santéisme. For the original version of this post, see L’individu devenu déchet. Pierre blogs at Pierre Fraser and tweets as @pierre_fraser.

Unlike some countries these days, America seems to have little difficulty tolerating the idea of multiculturalism. An explanation for this, perhaps, can be found in the American ideology of success. This ideology acts like a suction pump, removing any alternative explanations of how the world should work. This myth is contagious. The American dream – you can be whatever you want to be – circles the globe like a very powerful trademark.

In the myth of the self-made man, everything is possible. So powerful is this belief that nothing seems able to deter it. Contact with this idea creates the equivalent of an addiction. Every addiction, however, has its downside. We forget that every day “two types of trucks leave the factory: one type goes to the warehouse and department store, the other to the landfill. We have grown up with a story that considers only the first truck and ignores the second. ” [1]Read more

Share

SCOTUS, the Affordable Care Act, and an ugly American tradition

Romney: Repeal & Replace ObamacareI thought I had exhausted my need to read or listen to anything more on the Supreme Court decision on the Affordable Care Act (ACA). I read something today, however, that made me realize I hadn’t been paying close enough attention. It was an article published by The New England Journal of Medicine called The Road Ahead for the Affordable Care Act

The author, John McDonough, points out the significance of the upcoming November elections. In particular, he clarified for me why recent mentions of ‘reconciliation’ are not just referring to how the ACA was passed in 2010.

In January 2013, if Democrats hold the White House and Senate and regain control of the House, the ACA will be implemented mostly as constructed. If Republicans capture the White House and Senate and retain House control, the ACA will face major deconstruction early in 2013. Republican leaders will attempt to use Congress‘s budget-reconciliation authority to enact extensive repeal — and will need only 51 Senate votes, with no filibuster threat. If control of the White House and Congress is divided between the parties, then conflict over the law will persist. Thus, the November elections increasingly feel like a referendum on the ACA.

Read more

Share

What is healthism? (part two)

Apple and stethoscopeIn part one of this post I explained the most common meaning of healthism (an excessive preoccupation with healthy lifestyles and feeling personally responsible for our health) and described an authoritarian sense of the term. Here I discuss healthism as an appeal to moral sentiments and as a source of anxiety. I also note an unusual definition of the term as the desire to be healthy, which leads me to end with a personal disclaimer.

Moral healthism

The directive to be personally responsible for our health – whether it comes from a government health policy, the medical profession, or an advertisement – is often fraught with unacknowledged moral overtones. People who practice healthy lifestyles (daily exercise, a Mediterranean diet) and dutifully follow prevention guidelines (annual cancer screenings, pharmaceuticals to maintain surrogate endpoints for risk reduction) are overtly or implicitly encouraged to feel morally superior to those who do not. This includes the right to feel superior to those who ‘choose’ to be unhealthy – after all, isn’t smoking a morally indefensible choice? The implication is that those who fail to take responsibility for their health are undeserving of our sympathy or assistance (especially financial).

This quality of healthism – like the anti-authority healthism discussed in part one – is possibly more common in the US than elsewhere. It’s unfortunate but true that in the US there’s a tendency to blame the poor and disadvantaged for not being able to pull themselves up by their bootstraps. There is a decided unwillingness to acknowledge that differences in wealth and social class during childhood have lifelong effects on behavior and health.Read more

Share

What is healthism? (part one)

Apple and stethoscopeThroughout history there’s been an understandable desire to find connections between our behavior and our health. Human beings have practiced health regimens involving diet, exercise and hygiene since antiquity. When medicine was based on the humoral theory of disease, for example, individuals were advised to purge the body in the spring and, in the summer, avoid foods or activities that caused heat. Bathing in ice water was recommended in the 19th century. Mark Twain quoted the advice: “the only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d druther not.”

In the second half of the 20th century many Americans adopted the idea that a ‘healthy lifestyle’ (diet, exercise, not smoking, etc.) was a good way to prevent disease and live longer. This particular attitude was a product of popular perceptions about health (a surge of interest in holistic/alternative practices, self-care movements such as Our Bodies, Ourselves) and prevailing social attitudes (such as desirable body images). Perhaps more so than in previous centuries, the growth of media consumption and the effectiveness of modern advertising allowed commercial interests (books, magazines, fitness merchandise, vitamins and supplements, weight loss pills, diet and energy foods, …) to exert considerable influence on health behavior.

Also at work was extensive media coverage of a presumed link between preventive lifestyles and risk factors for disease (conflicting opinions about salt and which type of fats to eat are good examples). Unlike the vague aphorisms of previous generations, this more modern source of health advice had the scientific backing of epidemiology, if not the proof that comes from randomly controlled trials.

One of the terms used to describe the enormous increase in health consciousness is ‘healthism.’ Judging from how I’ve seen the word used, it means different things in different contexts to different people. I’m going to describe a few of those meanings.

This post grew rather long, so I’ve divided it into two parts. In part one I discuss an anti-authority sense of healthism as well as healthism’s most common meaning: a sense of personal responsibility for health accompanied by an excessive preoccupation with fitness, appearance, and the fear of disease. Part two discusses the moralistic and anxiety-inducing qualities of the term, plus an odd use where healthism becomes another word for health itself. Read more

Share

Guest post: Is the prevalence of depression related to the modern empowerment of the individual?

Alain-Ehrenberg_Das_erschoepfte_Selbst_Depression_in_der_GesellschaftPierre Fraser is an author, essayist, and (currently) a PhD candidate in sociology at Université Laval. Just as his most recent book (Tous Malades !: Quand l’obsession pour la santé nous rend fous) was being published, I met Pierre on Twitter, where we discovered our mutual interest in the subject of healthism. Pierre blogs at Pierre Fraser and tweets as @pierre_fraser.

This translation would have been impossible without the invaluable assistance of Jan Henderson (PhD in the history of science and medicine from Yale). Her work allowed me to revisit the original French text and enhance it, and in this sense, we followed the injunction of Karl Popper : the duty of clarity. I hope our collaboration will continue, because Jan and I are particularly concerned about the healthization of society, and we try to understand how health has become a social value. Feel free to send us your comments (Jan Henderson, Pierre Fraser).

Pierre Fraser, 2012

When a medical clinician examines a patient, she first determines the presenting symptoms, considers which bodily functions might account for those symptoms, arrives at a diagnosis, and provides the most appropriate treatment. But what if the presenting symptom is depression? As Alain Ehrenberg points out, “depression, like any mental illness, is not a disease that can be assigned to a part of the body.” [1] In fact, as Ehrenberg goes on to say: “when psychiatry can discover the cause of a mental illness, as happened with epilepsy, it is no longer a mental illness.” [2] Such has been the dilemma of the history of psychiatry.Read more

Share

Why medicine is not a science and health care is not health

MicroscopeHere’s something I read recently in a blog post (The Limits of (Neuro)science at Neuroskeptic) that started me thinking:

Will science ever understand the brain? …

The notion that humans are complex and hard, while nature is easy, is an illusion created (ironically) by the successes of reductionist science. Some of the biggest questions facing mankind for eons have [been] answered so well, that we don’t even see them as questions. Why do people get sick? Bacteria and viruses. Why does the sun shine? Nuclear fusion. Easy.

I started to write a simple reply, but it grew into the following.

Medicine is an applied science, not a pure science

It may be true that understanding the human brain is only an order of magnitude more difficult than understanding any other aspect of human biology. I’m uneasy, however, about putting ‘why people get sick’ in the same category as ‘nuclear fusion.’ Particle physics is a science. Questions can be asked and (usually) answered under the controlled conditions required by the objectivity that characterizes science.

Medicine is the application of certain sciences (molecular biology, biochemistry, medical physics, histology, cytology, genetics, pharmacology, neuroscience) to – ultimately — individuals. Each individual is the product of a unique, lifelong sequence of social, cultural, economic, and psychological (as well as physical, chemical, biological, and genetic) influences. To this day, we don’t really know why some people get sick and others do not. To my mind, that makes medicine an application of science – like engineering – not a science in itself.Read more

Share

Recommended (online) reading

Woman reading computerI’m still on “sabbatical.” Mostly reading. Thinking about what I most want to write about. I know what my interests are — the problem is, I have too many. Meanwhile, here are some blogs I enjoy reading.

Thought Broadcast by Dr. Steve Balt

Psychiatry is a controversial topic these days. We (speaking for myself, anyway) love to criticize the overprescription of psychopharmaceuticals, the medicalization of the slightest deviation from “normal,” and those psychiatrists who are eager to take “gifts” from the drug companies whose products they subsequently prescribe and promote.

I suspect people relate to psychiatry more readily than to the science of medicine. We’ve all known moments of slippage along the spectrum of mental health. We’d all like to understand ourselves better, something psychiatry used to promise before it tried to reduce us to the chemical interactions inside our brains.

Dr. Balt writes about all of this. What I especially like about his blog is his compassion for patients and his honest assessment of the psychiatric profession. His writing has a quality like Gawande’s: He maintains a strong personal presence without straying too far into the overtly personal.

To get a sense of Thought Broadcast, read Dr. Balt’s My Philosophy page. A recent post I’d recommend: How to Retire at Age 27. It’s on psychiatric qualification for disability. His point is that labeling (and medicating) someone as disabled does nothing to solve underlying social problems. It concludes:

Psychiatry should not be a tool for social justice. … Using psychiatric labels to help patients obtain taxpayers’ money, unless absolutely necessary and legitimate, is wasteful and dishonest. More importantly, it harms the very souls we have pledged an oath to protect.

Read more

Share

When the poor were contagious

Unsanitary living conditions 19th centuryWill the London riots raise questions about a world that doesn’t care about the socially disadvantaged? Questions, yes. But will that be enough to bring about a change in attitudes and policies? Probably not. Unfortunately, the situation will need to get much worse. Even when that happens, current financial interests are likely to prevail. A discouraging prospect, yes, but a struggle worth waging.Read more

Share

On sabbatical

Self-reflectionI’m taking a break from frequent blogging – want to take time to read, do some research, reflect, and think about what I most want to write about next. At the moment, my inclination is to write about the history of medicine, starting with the Enlightenment and the transformation of medicine into a science in the 19th century. I want to think about what light that sheds on the 20th century.Read more

Share

The Dreams of the Founders of Family Medicine

Marcus Welby MD on the phoneWhile they were mindful of and grateful for the powerful advances in medicine, they believed that social and economic conditions which influenced the life of a person and a community had a greater impact on a person’s life and health than did the power and might of all of medicine.

They believed that medicine was a profession that involved more than a technical set of skills and a high income. They accepted the responsibility of caring for the whole person; mind, body and soul.Read more

Share

Guest post: Guilt-edged

Bananas with the Globe and MailNow The Globe and Mail Life section reveals I could be guilty of hastening my demise by eating fruit. See The New Enemy in today’s paper, which warns that bananas are the arch enemy of the serious dieter and “that the high fructose content makes grapes and cherries as unhealthy as a plate of cookies.” Or not. Depending on which ‘experts’ you believe.Read more

Share

Is a liberal arts education good preparation for being a doctor?

Dr. Joel AngLiterature, fine art, poetry, music serve to remind overworked clinicians that they are part of a timeless tradition of healing whole human beings, who present in all their magnificence and complexity. Also, that physicians themselves participate in the tradition of physicians as humanists. Perhaps that’s why a liberal arts education – in my opinion – makes an important contribution to the practice of medicine today.Read more

Share