Navigating the Road from Disease to Health: Why Is There No Wellness General?

Moving from a disease focus to a health focus encompasses a way of being beyond lifestyle modifications or promotion of certain behaviors. Changing this paradigm examines how we live day to day and across a lifetime, and how many of the health challenges we encounter automatically occur as a byproduct of our modern way of life.  Many of us work sedentary jobs, with routines that can easily remove us from healthy ways of life. These issues are larger than individual, and must be addressed by communities, societies, and nations. Ultimately these are global problems.

How is the old model or paradigm outmoded or dysfunctional? Currently, we have a healthcare system which is actually a “sick care system”.  It is provider-centric, not patient-centric.  In our current system, the doctor “knows everything” and the patient “knows little” and is therefore unaccountable.  A larger issue of urgency exists in the culture as well: the public (i.e. patients) wants a “quick fix” (i.e. treatment).  If we want to affect the health of populations, we must find ways to move from our current reactive medical model to a more proactive social model.

What are the assumptions?  

A major assumption is that answers reside with medicalization and medical technology; it is a system set up to respond to acute illness, not preventive management of chronic disease processes. Medication is the predominant treatment strategy.  There is a “pass the pill” approach to disease management, and pharmaceuticals are viewed as a “cure all” approach in the treatment process. Change is needed. For example, instead of funding research on the treatment of heart disease, money could be rechanneled into primary prevention techniques to avoid the disease in the first place.

Another assumption is that technology is unilaterally a good thing and should be embraced, yet technology also presents complications. For example, gaming consoles and a culture of indoor, sedentary “play” has contributed to a childhood obesity epidemic, with our First Lady encouraging children to get outside and move. This would have been unimaginable a few decades ago.

A related assumption is that food is comfort: we celebrate with food and punish with exercise. A good grade is rewarded with an ice cream cone, not a run around the block.

We also have an assumption that teaching someone something means they will learn it, accept it, and adopt it.  Yet we face challenging cultural perspectives, where “being obese is a status symbol,” or cultures where certain ethnic foods are part of cultural identity.

An associated assumption is that behavior is individual; it’s actually social and community-based. Current health promotion models are too individualized, expecting individuals to make changes that need to be adopted systemically. New, innovative community, societal and national approaches to increasing public health will move health promotion forward.

What are the barriers? 

A central barrier is simply that change is hard. This is evidenced by the fact that our own National Prevention, Health Promotion, and Public Health Council (http://www.surgeongeneral.gov/initiatives/prevention/2013-npc-status-report.pdf, p. 2) is chaired by the Surgeon General. How is surgery the center of health promotion?  Why isn’t there a Wellness General? Below is a brief list of additional barriers we see:

§  Companies who profit from treating sick people will lose revenue if we become a healthier society.

§  Cost of sick care is profitable. Hospitals have reimbursed based on a fee for service model – thus incentivizing more service. With a shift toward preventive care, who will be reimbursed?

§  While people may understand the importance of eating healthy or increasing physical activity, they may lack motivation to change.

§  Our society does not allow for equal access for health.  Will the Affordable Care Act (ACA) really equalize this?  One annual visit is inadequate.

§  Environmental factors influence health across many facets of life

§  Access: getting healthy foods often requires transportation; exercising in one’s own neighborhood may not be safe

What Are the driving forces? 

Health is multidimensional, and requires a new way of thinking on many levels, not just the individual. Thankfully the shift to wellness and visions of a culture of health have some strong driving forces:

• Health care systems cannot adequately care for all the people in their vicinity.  We need to move toward health focused care in community-based settings and care for patients utilizing a more social model of care. Nurses can play a major role in providing such care.
• The cost of sick care is staggering – both monetarily and to the human being. This model is unsustainable.
• Personal interest is inviting increased knowledge of the long term impacts of lifestyle behaviors that negatively impact health (for example, smoking cessation), prompting personal choices to avoid specific behaviors

Community level drivers:  We see community level drivers within employer-employee relationships, workplace models that create community level change. People are forming their own communities for health (one way is by engaging technology and creating virtual communities using products like FitBit, My Fitness Pal)  Community level drivers also include entities like  local governments, tribal governments, families, neighborhood groups, faith-based groups and organizations, public health departments, teachers, city planning and engineering. Prioritizing health as a part of daily living in the community is exemplified in model communities such as those identified as Blue Zones (Buettner, 2005).

National level drivers:  A key national level driver is the federal government, with strategic plans  like the National Prevention Strategy Report-America’s Plan for Health and Wellness).  The National Council’s report (http://www.surgeongeneral.gov/initiatives/prevention/strategy/report.pdf) outlines both Strategic Directions and Priorities as follows:

Directions:

• Healthy and Safe Community Environments
• Clinical and Community Preventive Services
• Empowered People
• Elimination of Health Disparities

Priorities:

• Tobacco Free Living
• Preventing Drug Abuse and Excessive Alcohol Use
• Healthy Eating
• Active Living
• Injury and Violence Free Living
• Reproductive and Sexual Health
• Mental and Emotional Well-Being

Follow the link above. These are worth a look, illustrating the direction the driving forces can take. As we look at the National Prevention Strategy Report, it also becomes clear that the Department of Health is not the only federal organization responsible for this paradigm shift. Each department on the National Prevention, Health Promotion, and Public Health Council has an significant part to play as we navigate from disease to health. For example, we need to consider how the Departments of Agriculture, Education, and Transportation can all hold stronger roles in making this shift. 

National drivers can also include discipline-oriented and representative organizations (i.e. trade organizations, American Nursing Association, American Medical Association), health education groups, health care organizations, and big industries (i.e. pharmaceuticals, lobbying groups, etc.). Additional key players like the Robert Wood Johnson Foundation are leading the call in promoting a culture of health https://www.youtube.com/watch?v=rs4QSF6mxug.  

International level drivers: Globally, we think of organizations like WHO, Red Cross, and UN that can affect the promotion of health world wide. With a global economy, private institutions can also contribute, and may in fact have more impact on individuals.

Conflict, controversy, and tensions:

The issues of personal freedoms versus how much the government can legislate individual behaviors will continue to be a potential source of conflict and tension.  Examples include legislated safety issues such as wearing helmets for motorcycles and bicycles, using seat belts, and car seats.

Another controversy surfaces when people abandon the science and engage in health focused behaviors that may in fact be dangerously detrimental to their health;  e.g. avoiding vaccines, consuming unpasteurized food products, turning to alternative treatments as a decision fuelled by principles and not informed decisions.

We will continue to face challenges regarding resources, space, clean water, potential antibiotic resistance and superbugs with increased virulence of certain bacteria/viruses, pollution, and potential for increased poverty. 

Looking to the future 

So what does the future hold? What roles will need to change for everyone in this nation, including clients, communities, and health care providers alike?  A sorely needed Wellness General could concentrate efforts, and focus on improving health and infrastructure in every community – emphasizing healthy lifestyles, advertising healthy behaviors, and monitoring unhealthy products. We anticipate that hospitals will continue to serve intense, acute-care, research and observation needs, with a shift toward more registered nurses leading and coordinating interdisciplinary care in community-based wellness and health centers. The National Prevention Council’s National Prevention Strategy is a vital blueprint for future direction. Prevention is the new multidimensional model; “it takes a village” to keep people healthy.

References:

Buettner, D. (2005). Who’s best at living longest: The secrets of longevity. National Geographic, November, 6-26.

Christakis, N. A. and Fowler, J. H. (2007). The spread of obesity in a large social network over 32 years. . The New England Journal of Medicine, 357, 370-379.

Glass. T. A., and McAtee, M. J. (2006). Behavioral science at the crossroads in public health: Extending horizons, envisioning the future. Social Science and Medicine, 62(2006), 1650-1671.

National Prevention Council, National Prevention Strategy, Washington, DC:  U.S. Department of Health and Human Services, Office of the Surgeon General (2011).

Schroeder, S. A. (2007). We can do better – improving the health of the American people. The New England Journal of Medicine, 357, 1221-1228.

Links to Resources:

Surgeon General.gov http://www.surgeongeneral.gov/about/

Healthy People 2020  http://www.healthypeople.gov/2020/default.aspx

Social Security’s Financial Outlook http://crr.bc.edu/briefs/social-security%E2%80%99s-financial-outlook-the-2013-update-in-perspective/

Healthcare Paradigm Shifts http://www.njspotlight.com/stories/14/05/29/as-healthcare-paradigm-shifts-nj-hospitals-face-uncertain-future/

Health Issues  http://www.globalissues.org/issue/587/health-issues

Created by Participants in Nursing 7106 Context for Advancing Science (and Improving Health)

University of Utah College of Nursing PhD Program Summer 2014 

Submitted by:

Susan Gallagher, RN, MSN, GCNS-BC and Katarina Friberg Felsted, MS

(Lead Authors)