Presentation on theme: "I.H.F. Congress - Hong Kong - 2001 1 DEVELOPING A HOLISTIC VIEW AND APPROACH TO HEALTH CARE Even though certain forms of traditional medecine have survived."— Presentation transcript:
I.H.F. Congress - Hong Kong DEVELOPING A HOLISTIC VIEW AND APPROACH TO HEALTH CARE Even though certain forms of traditional medecine have survived in some countries such as China and India and even if in developed countries some still call on witch doctors and faith healers, scientific and rational western medecine has become universal. The underlying ideology of this type of medecine has historically been scientific physical and chemical reductionism. The recent human genome mapping is a prodigious example of this. In western medecine, health is seen as a repairer. Health means no disease or illness. Fuelled by scientific and technical progress health systems privilege providing specialist and effective treatment. This biomedical model is the dominant model in developed countries where, under the double influence of progress in medecine and the social welfare system's, a large part of the Gross Domestic Product is spent on the healthcare system. The effectiveness of a country's treatment system is even considered as one of the criterions of its economic development.
I.H.F. Congress - Hong Kong In Europe, public health policy (creating sewage systems, providing drinking water, building healthy housing) which followed industrial and urban development in the 19th century made it possible to fight off the dramatic epidemics. This has now left place for health policies turned towards individuals e.g. screening, health education. Sociocultural history can explain the differences which exist between different countries. Therefore public health is better developed in Northern European countries or Great Britain than in Southern European countries of latin culture. The developing countries especially the most impoverished who constantly face parasitical, viral and bacterial endemic diseases have a stunted treatment system. The majority of these countries' populations cannot access to expensive modern therapeutics for economic reasons. The health systems in these countries are reduced to no more than elementary types of prevention (health campaigns and innoculation).
I.H.F. Congress - Hong Kong The XXth century was an era of immense scientific progress. Curative medecine achieved great leaps forward. The prognostic of new growth in medical effectiveness over the next few years cannot be ignored with the perspectives of genetic therapy on the horizon. Paradoxically, various factors such as the accute consciousness as to the influence of collective determining factors on the health of individuals, the appearence of environment linked pathologies make for an approach to health, other than just reparing. Spectacular progress has been made with regards to life expectancy and the personal, social and economic consequences are not only felt in the West. Besides, the lengthening of life expectancy will have limits. Therefore should not health be lived according to the W.H.O. definition, as " a complete state of physical, mental and social well being " which " is not only the absence of disease or infirmity ".
I.H.F. Congress - Hong Kong I - THE PRIMACY OF THE REDUCTIONIST MODEL Medecine knew a pre-scientific era based on praying to divinities. Real scientific medecine was born with Hippocrate who recommended " taking the body of the ill as an object to be examined ". A strong reductionist approach has since gone hand in hand with progress made in medical science. The first disections carried out on human bodies opened the door to the knowledge of human organs and later to that of anatomical clinical medecine. Bichat, the frenchman identified the different categories of tissues which make up the human body. Vuichow the prussian discovered the cell, which, to him was the elementary centre of pathology. We went from histology (the study of tissues) to cytologie (the study of cells). The doctors attention focussed on smaller and smaller bodies. Progress in medecine owes a lot to physical and chemical science, to medical and biological engineering and now to information technology. Genetics are, without a doubt, one of the most prodigious illustrations of molecular medecine and the reductionist model.
I.H.F. Congress - Hong Kong In this biomedical model in which health appears as the absence of disease or illness and in which there is absolute faith in the power of medecine, the role of the health system and more specifically that of therapeutics is absolutely necessary. From the fragmentation of medecine were born hospitals organised around the treatment of organs (cardiology, pneumology, neurology). In parallel, the medical profession also split up into more and more specific branches, notably into somatic medecine. Other health linked professions have progressively emerged, become higher in number and more varied (physiotherapists, orthoptists, laboratory technicians etc). In certain health systems hospital practicians and local practicians are compartmentalised. Professional sectors have sometimes engendered corporatism aggravated by revenu linked logic in countries where professionals are paid fee-for-services. The hyperspecialisation and the compartmentalisation of the actors are now experienced as brakes to coordinated global care of the ill in the curative sector and more obviously to a global health policy.
I.H.F. Congress - Hong Kong In many developed countries the public health services remain apart from the treatment service at both administrative and financial levels. The public health services are traditionally administered by the State and, occasionally, by local authorities. In the bismark style model, the treatment services are financially under the responsability of sickness funds. We can even see such a compartmentalisation, in the beveridge style model where the government is supposed to be in charge of all the health services. We must also note that even if there is one Ministry of Health the division of responsabilities within the ministerial departments means that a certain number of policies which may have an impact on health are put in to place by other ministerial departments (housing, transport, etc) without any real coordination.
I.H.F. Congress - Hong Kong There are a certain number of limits to this biomedical model. It overestimates the role of the health system to which developed countries owe (according to specialists) only 10 to 20 percent of the progress made in the rate of mortality over the last 30 years. It is obvious that economic growth and better education have played a more important role in improving health than the treatment system itself. The biomedical approach does not sufficiently take into consideration the effect of collective determining factors e.g. the rate of pay, working conditions, lifestyle, on an individual's state of health. Finally, this approach leaves aside human relational care for technical care. Without mentioning the fresh interest in western society for a certain number of parallel types of medecine based on a holistic approach to health ; we can uncontestably witness the appearance of a certain number of trends which make for a more global, less curative based approach to health.
I.H.F. Congress - Hong Kong II - RECENT HOLISTIC TRENDS The fact that the biomedical model has its limits coupled with a certain number of contemporary factors favour a less illness based approach to health. At the same time, we can see the curative sector evolving towards patient orientated rather than illness orientated care. Firstly, a certain number of general factors have an effect on the health of a population e.g. ecological factors (the environment, work environment) economic factors (spending power) social factors (income, lifestyle) cultural factors (education, training). The 70's economic crisis in the developed countries and its effects on society highlighted the importance of determining social factors and their effects on hazardous behaviour such as tobacco consumption, alcoholism, or the use of drugs. We must not neglect the effects of the environment on the human being. Health is not only a medical but also an economic and social affair. The appearance of many diseases (A.I.D.S., Creuztfeldt Jakob's Disease) and the uncertainty they bring as far as diagnostics and therapeutics are concerned throws doubt on the biomedical model.
I.H.F. Congress - Hong Kong In other respects illness brought on by ageing (chronic illness, handicaps) lead us to putting the emphasis on seeking a better quality of life. The individual's idea of health is also changing. They no longer see it as the absence of illness or disease but as a notion of well being, feeling better and of physical performance. The W.H.O.'s definition of health had largely anticipated these ideas. Even within the treatment system, the fragmentation of contemporary medecine which is completely body and illness rather than patient orientated, is questioned. In the hospitals the neighbouring specialities are interacting. Better networks are being set up to coordinate hospital practicians and local practicians. Emphasis is made on multidisciplinary services and teamwork. Doctors and other health linked professions can be found in the same health centers.
I.H.F. Congress - Hong Kong Public health is once more an issue in developed countries, especially in Europe. Public health is seen as the " science and art of preventing disease prolonging life and promoting health through organized efforts of society ". The complexity of the determining factors of health and their interaction have led to a multifactorial approach on which promoting health is based. These factors are laid out in the Ottawa, Health Promotion Charter of 1986 in this charter 5 fields of action can be seen : - building healthy public policy - creating supporting environments - strengthening community action - developing the personnel's skills - reorientating health services. Many countries have now committed themselves to strategies based on the intersectorial approach. Some countries such as Denmark or Finland have even created interministerial committees whose role is to coordinate health policies. These approaches call for a wide range of disciplines like epidemiology, psychology, marketing, economics or anthropology.
I.H.F. Congress - Hong Kong What is more this " new public health movement " takes, advantage of the context of mastering the cost of the health system, an issue which developed countries are now confronted with. Knowing the smallest form of the hereditary molecule shows, in a most spectacular way, the effectiveness of the reductionist method which leads to great hopes in therapeutics especially in prevention and prediction. The biomedical model has a great future. Paradoxically genetics has also led us to understand the importance of the interaction between genes and the environment, future health policies should try to promote health systems based on global, a multifactorial approach to health. Alexis DUSSOL Chairman of the National conference of general hospital managers