Understanding the nature of health: New perspectives for medicine and public health. Improved wellbeing at lower costs

Life’s demands

Humans, like all other biological creatures, are exposed to the demands of life (Figure 1). Their fulfilment is a condition for life⁶. In people, these demands are physiological, psychosocial and environmental.

1. Physiological demands. Humans have to meet physiological needs that vary with time and circumstances. They present themselves in many ways related to input, output, homeostasis, work, and procreation. “Intake of oxygen, nutrients and water, excretion, fertilization, pregnancy and childbirth are key examples. Some specific characteristics differentiate humans from other higher animals, e.g., the choice of whether or not to procreate”⁴.

2. Psychosocial demands. “Psychosocial demands relate to individuals’ personal development and social integration, including participation in the social, economic and political life. All these are interlinked. Each individual is exposed to various social determinants of health throughout the life course, with varying roles and expectations, as related to jobs, relationships, obligations to family and society, personal aspirations and political and economic contexts”⁴. The way in which life’s psychosocial demands present themselves and can be fulfilled depends on the specifics of the respective individual and society. The final psychosocial demand is to achieve peace with the fact that every human must die.

3. Environmental demands. Environmental factors may decrease or increase the demands of life in many ways, thereby affecting personal health. Examples are availability of clean drinking water, conditions for food production, air pollution, radioactivity and safe workplaces. In addition, protection from physical, chemical, and microbiological threats and safe disposal of waste matter (recycling) is essential. Some of these are apparent immediately, while others could be latent for many years (e.g., exposure to carcinogens from tobacco smoke, pollutants or radioactivity).

Potentials

Each person needs resources to meet the demands of life. They have to satisfy the demands both in the present and in the long term. In order to serve the purposes of the Meikirch model the term potential was introduced to express both present and future resources. The potentials of an individual person have a double nature, parts are given and parts are acquired. Individuals always draw simultaneously on both potentials to meet life’s demands as outlined below.

Biologically given potential (BGP). The BGP represents the biological basis of life. At the moment of birth it has a finite value resulting from genetic equipment, epigenetic regulation and quality of the pregnancy. This is the gift of life everybody receives. This potential diminishes naturally throughout life, reaching zero at the time of death. Every substantial social disadvantage, somatic disease, injury, or defect diminishes the BGP either transiently or permanently.

Personally acquired potential (PAP). The PAP is the sum of all physiological, mental, spiritual and social resources a person acquires during life. Presumably it starts to develop in utero while the baby hears the heart beat and the voice of the mother and feels her bodily movements. After birth, as the brain and other organs mature, this potential increases rapidly. Interactions in families, schools, and communities play a pivotal role for children and adolescents in supporting their acquisition of knowledge and skills and personal development. Even in adulthood the development of the potential continues, provided an individual cares for it. The social determinants of health have a very important enabling or inhibiting function. Integration and participation in the society is of outstanding importance for each individual. The society also provides many other helpful possibilities, such as work, food shops, health information, social security, and a health care system. Finally, the environmental determinants of health exhibit decisive enabling and threatening functions for the PAP of each individual.

Social determinants of health

Social determinants may be supportive or challenging for people’s health by modifying the demands of life and by supporting or hindering the development of their potentials. This starts in families and continues in schools and during professional formation^7,8. These influences result from interacting individuals or as a result of the prevailing culture in the society. Throughout life social concerns, mutual trust, and collective efficacy support a good health outcome. Wilkinson and Pickett identified better health of people in countries with less inequality of incomes⁹. In many parts of the world the social determinants of health are not optimal. Poverty, difficult living and work conditions may limit the health people can achieve. “Longevity is not solely related to people’s income, but is also strongly affected by their autonomy and social participation, which are major determinants of health”⁸.

Environmental determinants of health

In 1987 the UN World Commission on Environment and Development’s report, Our Common Future, also known as the Brundtland report, noted: The "environment" is where we all live; and "development" is what we all do in attempting to improve our lot within that abode¹⁰. Factors in living and work environments may not be cared for sufficiently, e.g. global warming¹¹. Also coal mining is an important environmental cause of diseases as are water-borne contaminants. Use of antibiotics in agriculture has contributed to human infections with resistant germs. “Adopting cleaner, more sustainable energy technologies and water sources could help promote both health and development. At the macro level, dwindling natural resources, population growth, and the effects of climate change are likely to affect global health”⁴.

Health as a complex adaptive system

A complex adaptive system is an entity with a boundary between it and its environment, that can take up material and energy from the environment (input), release end products (output of entropy) and do work^12–14. Within the system there are many different parts called agents. They continuously interact with each other in a nonlinear manner, resulting in an outcome, called emergence, that is more than the sum of the properties of these agents. In the Meikirch model the five components, including their subcomponents, are regarded as agents (Figure 1). They spontaneously and autonomously arrange themselves in such a way that the evolving products are an emergent expression of the functioning of the system as a whole. These arrangements are operational, but are not necessarily the best solution for the system. Nevertheless, in complex adaptive systems, including humans, emergence is definitely more than the sum of the properties and functions of the parts.

In a complex adaptive system there is a flow of energy. Via their inputs all living organisms take up energy from their surroundings. Humans have within themselves an additional source of energy, e.g. vitality, drive and sense of purpose¹⁵. One part of the total energy is spent to maintain the person physically and emotionally and another part to do work. The material output (excretions) contains the end products and represents entropy. The flow of energy in human beings also leads to a desire for being loved, pursuing values, and living for a purpose. Investigating the double nature of this energy flow of an individual helps to better understand her or his state of health.

Modifying the demands of life

Environmental determinants of health have impacts on the two human potentials and on the demands of life (Figure 1). Geography may dictate, for example, how and which type of food can be produced, and how housing and clothing has to be. In addition, the demands of life vary with the social determinants of health. They differ in low income and high-income countries. Demands also vary from person to person and in different cultural backgrounds. In some places women are primarily concerned with raising children, whereas men care for food production. In others the tasks are different. But role models change continuously. It often appears that not much can be done to modify the demands of life. For young individuals, therefore, it is important to choose wisely among them and, if possible, get away from life conditions that are detrimental to health. In the future, for a given cultural background, this might be reflected in appropriate educational programmes.

Care of the biologically given potential (BGP)

After a healthy pregnancy the BGP at birth is a gift of nature and its vitality may vary from person to person. Thereafter it must be cared for. Social factors may foster or curb physical exercise, quality and quantity of food, alcohol intake, smoking, and consumption of narcotic drugs. These features are well known in pedagogy.

In earlier times epidemics have wiped out large portions of populations. Acute and chronic disease burdens threatened the BGP. Today, improved social determinants of health, e.g., public health and medical programmes, have achieved healthy lives and long life spans for a majority of the people in high income countries whereas low-income countries are still concerned with further developing their public health and medical services. Everywhere economic factors limit in one way or another what can be done for the BGP.

Promotion of the personally acquired potential (PAP)

The PAP is presumably the most fragile and modifiable component of the Meikirch model. It is subject to strong influences through interactions with other components of the model. The PAP is a critical factor for the achievement of satisfactory or unsatisfactory responses to the demands of life. Thereby it strongly influences the realization of health or disease. Consequently, it is of greatest interest to review the factors that may promote or impede the development of this potential.

1. Important factors that modify the PAP. In each individual this potential is small at birth, yet grows rapidly thereafter. From the first day children mature with the love and care of their parents¹⁹. Later, teachers play important roles. Eventually individuals have to assume responsibility for their PAP themselves. Yet, they remain affected by their social settings. Although every person continuously has to contribute him- or herself to this potential, it may be supported further by trusting, loving, respectful, and life affirming human relationships. A well-founded sense of purpose in life strengthens it also¹⁶. Alternatively it may be damaged by stress, adverse social circumstances like educational deprivation, sexual exploitation, and abuse of alcohol and narcotic drugs. Theoretically, at any moment, each individual has choices about how to handle his or her life situation. In order to choose from the existing possibilities as wisely as possible, each person develops more or less personal leadership¹⁷. Thus, the PAP of any individual is the result of complex interactions between the respective personality and his or her social settings.

2. A high PAP is important for health. The PAP is critical for the choices an individual makes about how to approach the demands of life. Affinity for certain types of work, ambitions, vitality, attitudes toward rewards, etc. will influence the choices of and dedication for work. These aspects apply equally to work at home, including attention to children as well as to work outside the home, e.g., professional contributions to the society. Ideally the specifics of each work situation are matched with knowledge and skills of each worker.

Attitude, culture, willingness to learn theoretically and from experience, and the possibility to grow with new challenges will have major influences on health. This is exemplified by several approaches: In his concept of salutogenesis, Antonovsky postulates that a high sense of coherence is essential for successful coping¹⁵. Comprehensibility, manageability and meaningfulness are central features of this sense of coherence. Presumably they can be learned and life managed correspondingly. Also van Spijk postulates that leading a life that makes sense results in “human great health”¹⁸. Martin Seligman found that positive psychology is closely related to health¹⁹. Flourishing persons who experience more than three positive feelings for every negative feeling are healthier and live longer than languishing persons. In the Meikirch model this may be explained by the contribution of positive emotions to the PAP. Overarching positive feelings or positive self-perception strongly influence the approach to life as shown by the following two studies. Nuns with more positive emotions at the age of about 22 years survived six years longer than nuns with more negative emotions at the same age²⁰. “Individuals with more positive self-perceptions of aging lived 7.5 years longer than those with less positive self-perceptions”^4,21. Other examples are given in Table 2. Methods to improve the PAP including its implication for health need to be investigated urgently and in depth.

3. Personal health leadership. In principle every person has considerable influence on his PAP. Consequently, in as much as humans are in control of themselves, it is necessary to consider that they also have to assume personal responsibility for their health. Correspondingly, they may or may not “lead a healthy life”. This popular expression implies that the importance of leadership for personal health has been known publicly for a long time. If so, everyone might be considered as an entrepreneur of his or her own health. This is an encouraging, positive empowerment for health that may motivate people to invest in it. This idea as expressed in the Meikirch model is now being practised successfully in indigenous villages in Odisha, India²². The essence of the model was easily understood even by analphabetic persons and it changed their behaviour into a much more health supporting pattern. Until now the idea of personal responsibility for health has not received sufficient attention. This presumably is due to the fact that in the past the origin of many diseases has been unexplained and therefore diseased humans were not to be made responsible unjustly. In 2003, however, WHO has launched its campaign against non-communicable diseases²³. These conditions are thought to be largely preventable by health protecting behaviour. This justifies the concept that all humans are called to assume personal leadership for their health.

4. Education for a culture of health. Leadership for one's PAP might further be reinforced by introduction of a culture of health²⁴. For this purpose all professionals of public health and individual medical care might be involved. They should teach about the Meikirch model and the relevant health conditions to students and lay persons from kindergarten up to professional maturity and old age. The principles for transformative learning worked out for health professionals may be applied equally to the general population²⁵. For example teaching patients with type 2 diabetes improved their health²⁶. Schools, universities, and the media should play an important role. Voices and actions of public role models might also be encouraging. In addition to the Meikirch model, easily understandable information about prevention and treatment of prevalent diseases appears to be essential for the general public. A central organization e.g., a “National Institute of Health Information” might be made available as a library and reference centre of trustworthy health information for the whole population. Once a new culture of health is established, an impressively improved health of the people most likely will be the result.

5. Vaccination and levels of control of infectious diseases. The grave lack of a culture of health is well illustrated by diseases such as poliomyelitis, and tuberculosis. In theory, poliomyelitis could be eradicated like smallpox by mass vaccination for all the people in the world or by surveillance containment strategies; in practice, concerted efforts by the WHO had it difficult to find acceptance in some countries, and major resurgences occurred in India and Nigeria, reintroducing polio virus type 1 into more than 20 previously polio-free countries²⁷. By adequate treatment of patients infected by mycobacterium tuberculosis, tuberculosis could be controlled. But, being essentially a disease of poverty, deliberate efforts and continued improvement of social determinants are necessary but were difficult to achieve, particularly in poorer countries²⁷. Although the WHO has made major efforts in this direction and has had much success, without mutual trust and support resulting from a culture of health embracing each and every person these goals probably cannot be attained.

6. Relationship between the two potentials. Interestingly, the proposed type of health leadership and self-management also applies to cultivating the complex relationship between the two potentials (BGP and PAP). An analogous relationship exists in the bond between a horse and its rider. If the rider wants his horse to serve him well, he must take good care of it. The horse needs cleanliness, adequate food and water, an appropriate amount of physical movement, and rest at night in a protected area. In addition, horse and rider must trust each other and the rider must remain in control. Although this analogy with the relationship between a person and his body may be surprising, it illustrates that the two potentials must remain at one with each other. Further features render this relationship important: To a significant part the PAP can compensate for defects of the BGP. This ability is used in rehabilitation. In some conditions it may go quite far. E.g. paraplegic patients may again become independent and professionally active²⁸. When asked, they may even say that they are “healthy”. The compensation of defects in the BGP by the PAP is also important for elderly persons who experience increasing somatic defects. Yet, after having learned to adjust to them, they may experience a sense of well-being and lead a very satisfactory life.

Social determinants of health

Social determinants of health are of fundamental importance²⁹. Among other aspects they are complicated by the fact that health care also has an economic component. This has been well known since antiquity. Today, health economy has a much higher and ever increasing impact because health care systems have become more and more costly.

1. Epidemics. The relation between social determinants of health and the PAP becomes vital in case of epidemics, as exemplified by the Ebola crisis in West Africa in 2014³⁰. It clearly illustrates the needs for careful investigation of the disease itself, interruption of its transmission, and care of the diseased persons. This means that people have first to understand the disease and what they must do for prevention and for treatment of diseased individuals. They must then become convinced of the purpose of what they do. Last but not least they have to receive the equipment and support they need to become effective. To achieve appropriate handling of diseased individuals, a corresponding organization is essential, particularly because in most cases cultural limitations may have to be overcome. This requires appropriate educational interventions and intense interactions between the responsible organization and the population. An educational programme based on the Meikirch model may be very useful, because it explains the importance of a PAP and gives all participants an identical view about how social determinants of health contribute. Successful cooperation requires agreed upon, common objectives³¹. The Meikirch model might be most appropriate for this purpose.

2. Tragedy of the commons. In high-income countries many current health care systems offer various services at no or minimal extra costs beyond the ordinary premiums for health insurance. For Germany, the OECD has documented 9.9 average “episodes of care” versus 6.6 for the OECD average of 33 countries, which is the highest in Western Europe. This is not limited, and for each “episode of care” multiple physician contacts are involved³². Patients with compulsory insurance had a mean of 18 physician contacts per year in 2007 (8 physician contacts in the age group 11–15 years; 37 physician contacts in the age group 81–85 years) according to one large insurance company³³. Although it is difficult to interpret such statistics, they document overuse in a wealthy country. Hardin has compared such situations to the so-called “tragedy of the commons”³⁴. Whenever a utility is freely available to everybody and paid collectively, it follows logically that everybody tries to get as much out of it as possible. This is no problem as long as the utility is available in excess. The tragedy begins only once the utility becomes the limiting factor. In the past this occurred when farmers used the commons to feed their cows. Every farmer added one or two cows to his allowance. Overgrazing resulted in the tragedy of insufficient feed at the end of the season: the so called “tragic depletion”. Interestingly there is no technical solution to this problem. The tragedy only stopped once the commons were distributed among the farmers as property and each of them had to be satisfied with the amount of land he disposed of. Such a change is, according to theory, often prevented by the “tragic stalemate”: nobody wants to do the first step³⁵. Today such arguments may be applied to the use of health care services, as was observed for the USA^36,37. In analogy, the continuous rise in health care costs will not be stopped by appeals and rationing will produce undesired effects. It will become limited only when each patient establishes ownership of his or her health and will assume more responsibility for his or her own health care, including financial consequences. Such a condition might further strengthen health leadership as explained above. Implementation of financial responsibility of individuals for their healthcare, however, will be difficult to introduce. Obviously it must be developed by trial and error without undue hardship for socially disadvantaged groups. Health economists, ethicists and politicians will have to work together. The Meikirch model may facilitate convergence of more or less affluent countries as recommended by the WHO Commission on Social Determinants of Health²⁹.

3. Influence of health care payment models on physician work practice and professional satisfaction of all involved participants. Payment models are designed to produce financial incentives in order to achieve certain goals. Examples are capitation, episode-based and bundled payment, shared savings, pay for performance (PFP), and retainer-based practice³⁸. They are designed from different points of view e.g. to “improve patient care, to preserve or enhance physician professional satisfaction, to satisfy multiple external stakeholders, or to maintain economic viability as business”³⁹. Porter’s proposal e.g. intends to improve “value” in health care⁴⁰. The proposal is formulated from the point of view of the payer. Other actors in the health care systems may have different points of views⁴¹. The most important concern is that payment systems may be manipulated for personal gains. Yet, once patients no longer are sure that their physicians act exclusively in their best interest, the patient-physician relationship is strained⁴². Today there are many examples of manipulation. Bernard Lown et al.^43,44 have shown this phenomenon in cardiology, but other fields of health care are equally vulnerable. The Meikirch model offers a new point of view. In each individual patient the primary aim of a payment system should be to optimally support improvement of health as defined by the model. If all interested parties share this objective, payment systems may be worked out that fully protect the patients interests, serve all partakers, and thereby also are cost-effective⁴⁵. If these conditions are fulfilled, the payment systems also will lead to professional satisfaction of physicians and other interested parties.

4. Moral hazard. Moral hazard may occur when insurance payments change the behaviours of patients or physicians. This is possible for cases with diseases or treatments that are difficult to assess objectively. Such situations may therefore be exploited by patients in order to get payments^46,47. Independent medical evaluations for social security eligibility may then become necessary. The Meikirch model was found to be useful also for such evaluations⁴⁸. As outlined above, moral hazard undermines mutual trust between diseased persons and physicians. A shared vision of health as set out by the Meikirch model may make it easier for physicians to improve performance and accountability and for patients to truly agree on indications, e.g., for expensive examinations and for surgery^40,41.

5. Stressful working conditions. Social determinants contribute to both the demands of life and the two potentials⁴⁹. For instance, during the industrial revolution the majority of employees had to work very long hours and often in unhealthy settings. Unfortunately, in many low or middle-income countries, such practices have not as yet been stopped. Working conditions evolving from a continuous mutually supporting dialogue between the workers and management may render engagement in a working place more interesting, more flexible, more rewarding and particularly also more productive⁹. “Economists have recognized that good communication between workers and management, leads to better working conditions and may result in important productivity gains while simultaneously reducing costs⁵⁰. If such communication includes the Meikirch model, health of the employees might be improved and health care costs reduced.”

Environmental determinants of health^11,51

The relationship between social and environmental determinants of health offers another excellent example of the tragedy of the commons. The environment is freely available. Therefore in many places it is used without restrictions and poisoned correspondingly. When the population was small, waste created no problems, and nobody had to pay for it. Population growth, technological developments, and increase in wealth, however, have now led to major problems. In Switzerland, for example, most lakes were polluted to an extent that life in the water became almost extinct. When waste water was cleaned before it was allowed to flow into the lakes, water quality was much improved. Today, a worldwide overproduction of CO₂ and other waste products increase greenhouse gases to an extent that the temperatures of the planet will rise. Atomic power plants create an analogous situation. Everybody needs electrical power, yet nobody knows what to do with the atomic waste. In addition, the Fukushima catastrophe has again revealed how dangerous accidents in atomic power plants may be. A further example is exploitation of some fish populations that led to their extinction. Pollution of air, water and soil has serious consequences in many places. Therefore, for the purpose of health, many new agreements and their strict enforcement will be required in order to correct the current untenable situation.

Health and disease as states of a complex adaptive system

Investigation of the state of health of an individual by a systems theoretical approach is as yet in its infancy, but scientific methods based on Newtonian physics are inadequate (Table 3 and Table 4)^12,13. A new approach should involve individual health as a whole (Figure 1), should consider its history, its energy flow and its sense of purpose.

As a first approximation the system’s approach comes close to the best of the old fashioned medical history. The patient is to be carefully asked at least the following questions: How was life before onset of the disease? What were the weaknesses and the strengths? How were the conditions around the time of the first symptoms? What was new? What were possible triggering or helping factors at that time and also during further episodes of the disease? How did the patient’s sense of coherence (understandability, manageability and purpose) evolve during the disease?¹⁵ What was the purpose in life, and what is it now? How does the patient himself interpret her or his symptoms or condition? How did the patient respond to the different stages of the disease? What could be the most appropriate evolution for the patient and how does she or he see it? These questions may then be modified to try to assess the energy flow, including energies driving preferences of behaviour, values and spirituality. Specific questions about the purpose in life may inform about some of these aspects^14,52.

Systems methods may particularly be applied by general practitioners, because very often they have known the patient for years, are also aware of his or her social network and have gone with him or her through previous crises. A long-standing and trusting patient-doctor relationship is a most powerful diagnostic and therapeutic tool⁵³. In many cases modern diagnostic procedures, expensive drugs or seemingly appropriate surgical interventions can be avoided, because they involve risks and encompass unpredictable reactions of the patient’s system. Such restraint may be wise and prevent complications. Reorientation of the patient’s intentions and sense of purpose may induce healing processes. Active participation of the patient is important. Similar considerations apply in rehabilitation institutions, where patients may be observed closely (Table 4).

This brief allusion reveals that at the present time system’s thinking in medicine is at its very beginning. For appropriate treatment of the PAP much further diagnostic and therapeutic research is needed. Systems theory has a good chance to evolve to a very powerful tool in the coming years.