There’s more to health than our me­chan­i­cal parts

The Globe and Mail Metro (Ontario Edition) - - OPINION - SHOLOM GLOUBERMAN

Philoso­pher in res­i­dence at Bay­crest Health Sci­ences in Toronto and the founder of Pa­tients Canada. His lat­est book is The Me­chan­i­cal Pa­tient: Find­ing a More Hu­man Model of Health.

The med­i­cal model that in­forms the train­ing of doc­tors and the care of pa­tients – a model that mod­ern medicine has fol­lowed for 300 years – con­sid­ers peo­ple to be ma­chines with or­gans, limbs and chem­i­cal pro­cesses. A widely ac­cepted def­i­ni­tion says that health is “the level of func­tional and meta­bolic ef­fi­ciency of a liv­ing or­gan­ism.” Here, health is seen to de­pend on the ex­tent to which our limbs and or­gans work well and the de­gree to which the me­chan­i­cal sys­tems of our bod­ies are in good re­pair. Ac­cord­ing to this, we are me­chan­i­cal pa­tients.

But we are not me­chan­i­cal. How we are treated by doc­tors is at odds with much of our un­der­stand­ing of hu­man be­ings. We are not in­di­vid­ual me­chan­i­cal sys­tems, but so­cial an­i­mals, closely con­nected to other peo­ple from birth. Un­like many other an­i­mals, we can­not sur­vive in iso­la­tion. We are ut­terly de­pen­dent on oth­ers to care for us as in­fants – to feed us, to dress us, to pro­tect us from or­di­nary dan­gers. We can­not learn to speak with­out in­ter­act­ing with other peo­ple, and we can only think in a lan­guage that we learn from them.

But when it comes to our health, we fall back on the no­tion that some­how we are iso­lated in­di­vid­u­als whose health is un­der­stood as the proper func­tion­ing of our limbs and or­gans and the main­te­nance of ap­pro­pri­ate bod­ily flu­ids. We are con­stantly ad­vised to eat healthy food and ex­er­cise the right amount in or­der to be healthy, which is all well and good in main­tain­ing the me­chan­ics of the hu­man body. But very lit­tle is said about the so­cial and re­la­tional con­trib­u­tors to our in­di­vid­ual health.

This is not sur­pris­ing. Seven­teenth-cen­tury me­chan­i­cal philoso­phers such as René Descartes and sci­en­tists and chem­i­cal re­searchers such as Robert Boyle de­clared that the body was a chem­i­cal/me­chan­i­cal en­tity. They made a strong distinc­tion be­tween the spir­i­tual, non-ma­te­rial mind and the phys­i­cal, mech­a­nis­tic body. The distinc­tion re­mains deeply em­bed­ded in our think­ing – even when we know it is mis­taken.

Some re­cent changes have made this mis­take more crit­i­cal. A good ex­am­ple of such a change is the sig­nif­i­cant re­duc­tion in deaths from com­mu­ni­ca­ble dis­eases be­tween the late 19th cen­tury and the end of the 20th cen­tury. By 2012, ac­cord­ing to the World Health Or­ga­ni­za­tion, more than 95 per cent of deaths in de­vel­oped coun­tries were due to non­com­mu­ni­ca­ble, mostly chronic dis­eases such as cancer, heart dis­ease and type 2 di­a­betes. There is good, grow­ing ev­i­dence that many chronic con­di­tions are cor­re­lated with a wide va­ri­ety of so­cial/re­la­tional fac­tors, many of them out­side the pa­ram­e­ters of the chem­i­cal/me­chan­i­cal as­pects of the pa­tient, but it has so far proved dif­fi­cult to change the med­i­cal re­search agenda to in­clude them. So our treat­ments con­tinue to be largely con­fined to drugs and surgery – chem­i­cal or me­chan­i­cal in­ter­ven­tions.

This, too, is not sur­pris­ing. The tra­di­tional model that forms the ba­sis of med­i­cal ed­u­ca­tion re­mains that of the chem­i­cal/me­chan­i­cal pa­tient. For­mal med­i­cal di­ag­no­sis and treat­ment of most non-com­mu­ni­ca­ble dis­eases re­main ei­ther chem­i­cal – largely through the use of chem­i­cal tests and phar­ma­ceu­ti­cal agents – or me­chan­i­cal, by means of imag­ing and func­tional tests or surgery. In fact, very lit­tle of pa­tient di­ag­no­sis and treat­ment by con­ven­tional physi­cians in­cludes an in­ves­ti­ga­tion of the so­cial and re­la­tional sit­u­a­tion of pa­tients or their fam­i­lies.

An ex­cel­lent test for over­all health is longevity. Lon­gi­tu­di­nal stud­ies in Bri­tain start­ing in the 1970s rec­og­nized that so­cial and re­la­tional fac­tors con­trib­ute to health and ill­ness. The Na­tional Child De­vel­op­ment Study, for ex­am­ple, con­sid­ered the lives of more than 17,000 peo­ple born in Bri­tain dur­ing the week be­gin­ning March 3, 1958. It looked at the co­hort soon af­ter birth, then again at nine ad­di­tional times from 1965 to 2014. The results are sig­nif­i­cant. They con­firm that the health of this pop­u­la­tion is closely re­lated to so­cial and re­la­tional fac­tors. They showed that those who over­came so­cial dis­ad­van­tages did so as a re­sult of a wide va­ri­ety of re­la­tional re­sources, in­clud­ing fa­mil­ial sup­port, such as parental de­ter­mi­na­tion to as­sure proper school­ing; be­hav­ioral re­sources, such as hav­ing a sta­ble bed­time; and per­sonal re­sources, such as gain­ing plea­sure from recre­ational read­ing.

The Har­vard Study of Adult De­vel­op­ment be­gan in 1938 and fol­lowed 700 men and some of their spouses for more than 75 years. Those sub­jects who are still alive are in their 90s. A ma­jor con­clu­sion is that the great­est con­trib­u­tor to health into old age is strong, lov­ing re­la­tion­ships. Peo­ple who main­tained close fam­ily ties and good friend­ships for a very long time re­mained health­ier and hap­pier into old age than those who did not. The Har­vard study is of the so­cial/re­la­tional re­sources of a par­tic­u­larly priv­i­leged group. Even at the top of the so­cio-eco­nomic scale, there are dra­matic dif­fer­ences in health that are de­pen­dent on the qual­ity of re­la­tional in­ter­ac­tions.

A so­cial/re­la­tional model of health as­serts that healthy hu­man be­ings are not iso­lated minds in chem­i­cal/me­chan­i­cal bod­ies, but peo­ple in the world who en­gage with oth­ers in many ways, in a wide ar­ray of set­tings and with mul­ti­ple pur­poses. This view is re­in­forced by sci­en­tific re­search about the need for con­nec­tions with oth­ers for healthy hu­man de­vel­op­ment. Ev­ery­thing from brain de­vel­op­ment to emo­tional ma­tu­rity de­pends on con­nec­tions to other peo­ple. Our med­i­cal model must change.

A so­cial/re­la­tional model of health as­serts that healthy hu­man be­ings are not iso­lated minds in chem­i­cal/me­chan­i­cal bod­ies, but peo­ple in the world who en­gage with oth­ers in many ways, in a wide ar­ray of set­tings and with mul­ti­ple pur­poses.

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