Martin Sprenger, firstname.lastname@example.org
General Practitioner, Master of Public Health
Medical University of Graz, Universitätsplatz 4/3, 8010 Graz, Austria
Tel.+ Fax: 0043-(0)316-326896
During the 20th century many scientific disciplines have undergone a profound paradigm shift, which emanated from empirical reevaluations of the universe’s basic matter. Medical science has not followed yet, and in the 21st century, modern Western health care is still dominated by a narrow, monocausal, reductionistic view of health and disease. Recent findings about the phenomenon of self organisation and the characteristics of complex adaptive systems, as well as findings in system theory, socio-epidemiological research and psychoneuroimmunology compelled a critical reappraisal of current health care models. This paper reviews the literature to generate a discussion about a practical, scientifically sound and socially accepted model of health care at the interface of public health and general practice – primary health care and our communities – and to provide evidence that primary health care and the community is the ideal setting to learn more about the organism-environment link and in turn about the determinants of health in individuals as well as populations.
Keywords: General Practice; Public Health; Primary Health Care
It is recognised internationally that good primary health care is of fundamental importance to the improvement and maintenance of health, while containing the cost of health care systems as a whole. This was the main driver to reshape the role of primary health care in many countries and worldwide, public health and primary health care are drawing closer together. These changes in health care organisation and health care policy have forced a reappraisal of the traditional relationship between two branches of medical practice; public health and general practice.
Both disciplines have been marginalized in the last few decades, in relation to clinical medicine e.g. resource allocation, research, and training. At the same time, both disciplines are emerging as suitable organisations to shape the health care systems of the future. The reason being that on one side, public health recognises the growing evidence that social factors are powerful determinants of health in the developed countries. And on the other side, general practice stands at the centre of generating research designed to learn more about how meanings and experiences impinge on the health status of individuals. The vision is to merge the knowledge gained from both ends of this spectrum to a new understanding of the circumstances associated with the maintenance of health and the genesis of disease. This should be possible both for populations and individuals.
Primary health care is the bridge between specialist (secondary/tertiary) medical care and public health, and the community is the bridge between the individual and the population. Primary health care and the community are at the interface of public health and general practice. Both are under-researched, but are important areas for future study.
In the definition provided by the Alma Ata conference, which describes primary health care as the integral part of the country’s health system, integral primary health care has two interfaces: on one side it interfaces with specialist care and on the other side the interface is with the population – the first level of contact of individuals, the family and the community with the health system. At both interfaces primary health care should provide essential health care based on practical, scientifically sound, and socially acceptable methods and technology, which should consider the determinants, definitions, and inequalities of health, in individuals as well as populations.
There are striking differences between both interfaces; the interface towards specialist care is mainly an interface between health professionals, dominated by doctors, driven by technology and a biomedical concept of health and disease. At its best, it is well organised and researched, and provides evidence-based integrated medical care. The second interface is the gate towards the self-care health system and the population. It is the work area of health professionals from various disciplines (e.g. GPs, nurses, physiotherapists, social workers, public health professionals, midwives, pharmacists, psychotherapists, community workers), with close affinity to individuals and communities.
Primary health care and its interface with the community is an under-researched area. Nevertheless, it is that area of health care in the 21st century which provides plenty of scope to improve our knowledge about the importance of psychosocial factors; the relationship to our health, how they affect us as social beings, and what role they play in the genesis and treatment of disease.
In the biomedical model, health is defined as the absence of disease. The World Health Organisation (WHO) defines health as a dynamic state of complete physical, mental, spiritual and social wellbeing and not merely the absence of disease or infirmity. A literature review on definitions of “health” found that “health” is not as readily articulated as one might assume. At present, it is not clear if "health" refers to the individual, the community, the environment, or all of these at one time.
Societies in the affluent countries are moving from the industrial age into a new era, which is marked by an entirely different set of principles and values. Facets of globalisation have significantly reorganised time and space. Health systems and health determinants are far from peripheral to these developments because health, illness, health systems and services, medicine and public health have always reflected and contributed to the fashioning of modern culture and society.
At the beginning of a new millennium, health is still unequally distributed in the developed countries of the world and the provision and structure of health services had apparently no impact on the issue. In recognition of the evidence that the health gap between groups inside populations is still widening in almost all countries, the WHO adopted a set of principles known as the. The charter subscribes to the principles that: health care should be driven by values of human dignity, equity, solidarity and professional ethics; targeted on health; centred on people; focused on quality; based on sound financing; and oriented towards primary health care. Unfortunately, the fundamental principles, and the principles for managing change, do not mention the urgent need for high quality primary care research on important health problems, which provide empirical support for the reorientation of health services and public health policy in the 21st century.
Different approaches to analyses produce different pictures of the determinants of health and health inequalities. The challenge lies in the task of integrating the observations and findings to a broader scientific theory of health. At the moment, the biomedical model represents the only scientific theory of health with an underlying logic of disease pathways. The biopsychosocial model is broadening the term, but it cannot explain the links between; the psychosocial environment and the genesis of disease, the regeneration and maintenance of health, the mechanism of resilience, empowerment, and salutogenic orientated strategies. Hence, the positioning of biomedicine provides strong scientific arguments, while biopsychosocially orientated models struggle with intangible justifications when confronted with scientific scrutiny. In other words, if analogous insights are to inform our biopsychosocial understanding of health and disease, empirical research is required to support or negate what still remains a defensible but in many ways unproven model of health care.
What is the reorientation of natural science? Put simply, the reorientation of natural science during the twentieth century hinges on the importance and the problem of the observer. This fact was introduced into physics one hundred years ago by Max Planck (1858-1947) and others.
In contrast to modern physics the scientific concept of medicine is still a classic one. It remains a one-dimensional, linear, cause-effect, stimulus-response model, based on the reductionistic method of Rene Descartes (1596-1650). Cartesian thinking, which breaks the complex world into smaller, more manageable pieces argues that if we can understand the separate pieces, we can combine this knowledge to comprehend the whole (so called reductionism). Cartesian thinking, which has gradually produced a technically efficient but increasingly narrow, monocausal, reductionistic view of health and disease, prevails in medicine. Medicine sticks to the existence of an objective reality and an objective cause-effect relationship. It holds to the belief that the functioning of whole organism can be explained by understanding its elements. Following this principle, medicine started an extraordinary story of success. At the same time, by adopting the reductionistic model of classic natural science, medicine departed from a scientific model for living systems.
The following summary of eight characteristics of living systems is not a list of separate entities. Because a comprehensive theory of living systems is still lacking, it has to be seen as an overlapping list of different perspectives describing the unknown whole. It is an attempt to show the limitations of the present biomedical model and opportunities for its extension to a more practical, scientifically sound and socially accepted model of health and disease.
1. Living systems are thermodynamic open systems.
The second law of thermodynamics, by Rudolf Clausius (1822-1888), suggests a progression from order to disorder (entropy), from complexity to simplicity, in the physical universe. Yet biological evolution involves a hierarchical progression to increasingly complex forms of living systems, seemingly in contradiction to the second law of thermodynamics. In reality this contradiction does not exist, because the law of entropy is just valid for closed systems. Living systems, which are in a state of a permanent exchange of energy with their environment, are open systems. The maintenance of living systems requires that the energy flow through the system be of sufficient magnitude that the resulting negative entropy production rate be greater than the rate of dissipation that occurs from irreversible processes going on within the systems. The basic principle of human existence is not balance and health but imbalance, which contains the risk of disease and suffering. Disorganisation and the tendency toward entropy are omnipresent in living systems.
2. Living systems are dissipative systems.
Systems which are bound to a flow of energy to maintain their structure and which are in a state of energetic imbalance with their environment (otherwise they would soon merge into their environment) are called dissipative systems. This term goes back to the physicist Ilya Prigogine (1917- ) who was awarded the Nobel Prize in 1977. Three aspects can always be found in dissipative systems: the function, which is expressed by the chemical formula, the space-time structure, which results from instabilities, and the fluctuations, which trigger the instabilities. The importance of dissipative systems is only now being fully realised. Research into dissipative systems is being conducted on a considerable scale. Such systems play an important role in the control and fine-tuning of enzyme reactions, the biosynthesis of proteins, and many other vital processes inside of an organism.
3. Living systems are self organising
All natural systems are created by self organisation (autopoiesis) and are organised accumulations of matter/energy in a continuum of space and time. Francisco Varela (1946-2001), creator together with Humberto Maturna (1928-) of the theory of autopoiesis, describes autopoietic as the process whereby an organisation produces itself. The phenomena of self organisation refer to a universal law, which is of overriding importance to physical laws.
The limitations of the biomedical model, which is based on dead matter, completely controlled by the laws of classic physics, are obvious. Only recently, interesting experiments have been made about the self organisation of molecules, deoxyribonucleic acid (DNA), and self organisation in the physiology of disease and aging.
4. Living systems have the ability of self-reference and self-reflectiveness.
Well-known scientists have shown that the content of our perception is less determined by the characteristics of the environment then by the condition of the perceiving subject. When the system’s internal complexity is so great that it can no longer meet its needs by trial and error it needs to evolve another level of awareness in order to weigh different courses of action; it needs, in other words, to make choices. Decision-making brings about self-reflexivity.
5. Living systems are in a permanent interaction with their environment.
The ability to change their state of order means that living systems are able to adapt, learn and develop over time. There is no functional rest period. Complex adaptive systems can be found everywhere; examples include the immune system-, blood clotting-, and hormone system, a colony of termites, the financial market, and just about any collection of humans. The behaviour of any complex system is fundamentally unpredictable over time. The reason being that the elements are changeable, the relationships are non-linear, and the behaviour emergent and sensitive to small changes.
In reference to the adaptation syndrome, the biologist Hans Selye (1907-1982) founded the concept of stress. The ability to cope with stress changes with the individual, the situation and time.
6. In living systems mind and body are not separate unities
The biomedical model does not encompass the complexity of living systems and still perceives that mind and body as exclusive entities. As a consequence, most clinical disciplines fall into the category of either one or the other. According to the modern science is discovering that, while it is operationally convenient for purposes of discussion to separate mental health from physical health, this is a fiction created by language.
7. Living systems construct their own, subjective realities
Immanuel Kant (1724-1804), Jean Piaget (1896-1980) and many others have forced science to realise that living systems construct their own, subjective realities. Every observation, including a scientific observation, cannot be an objective projection of the world, because the observer influences the process. Although many simple everyday observations and measurements may not be influenced to any significant degree, this fact is a major problem for the observation of complex objects and interactions.
8. Living systems consist of systems and are, simultaneously, integral parts of larger systems
All living systems, be they organic like cell or human body, or supra-organic like a society or ecosystem have a dual nature: They are both wholes in themselves and, simultaneously, integral parts of larger wholes.
In the 1970’s, research in the social sciences, psychology, and psychosomatic medicine, demonstrated that psychological and social factors are relevant to the emergence and the progression of disease. These findings triggered heated debates about the limitations of the pathogenic biomedical model. In the 1970s, the American-Israeli medical sociologist Aaron Antonovsky (1923-1994) began to develop the salutogenic model of health and illness, which attained world wide professional attention, especially in the fields of prevention and health promotion.
The inception of the salutogenic and biopsychosocial model occurred at about the same time as the community psychology movements that formulated the concept of empowerment and socio-ecological approaches. These developments influenced the Alma Ata conference in 1978, where the WHO pronounced its overall goal “health for all by the year 2000”, and also the first International Conference on Health Promotion, which was held in 1986 in Ottowa.
Similarly as the salutogenic model the empirical foundation of the health promotion model is limited. At the moment health promotion activities are related to health in a non-specific way. As long as a solid theory of health is missing, we are unable to clarify what health promotion work is, and whether health promotion interventions have been successful.
General practice stands in the centre of multidisciplinary primary health care and is the gate to the self-care health system, the community, and the population; in addition it is usually the first point of contact with health services. General practice cares for patients in health, at the earliest and advanced stages of disease, and at the end of their life. Therefore, they know best about the personal, social, occupational, cultural and biological environment in which the illness of their patients evolves.
They are perfectly suited to shift the focus of psychosocial research from laboratories, academic medical centres, and epidemiology departments back to the place where it is best-learned – primary health care and communities. This will enable us to better understand the implications of different forms of insecurity in relation to housing, income and jobs, of social and community development, the determinants of the subjective quality of life, the reasons for unhealthy and help-seeking behaviour, the capacity of the self-care system, the importance of social fabric of society, the effects of hierarchy, social position, deprivation, the individual experience of illness, the “healing effect” of the doctor-patient relationship, the existence and persistence of health inequalities, etc.
Since the Alma-Ata conference in 1978, which outlined a broad vision of primary care and public health, issues at the interface between public health and general practice have not been discussed in great detail. A review of literature spanning the last twenty years in relationship to Great Britain found one predominant message. The benefits of collaboration between primary health care and public health have long been recognised, but only partially realised, despite a huge shift of public health work into general practice, contributing to its redevelopment as primary health care.
At the beginning of a new millennium, general practice and public health stand at the centre of research initiatives developed to learn more about the circumstances which are associated with the maintenance of health and the genesis of disease. In the 21st century, epidemiological, demographic, and socio-economic changes will present enormous challenges to health care systems in general and primary health care in particular. In order to meet these challenges, the obstacles between public health and general practice have to be removed.
GPs and public health professionals are ideal expert partners in interdisciplinary primary health care teams. Primary health care has the opportunity to lead interdisciplinary scientific research designed to learn more about the role of our psychosocial environment in the genesis of disease, the regeneration and maintenance of health, and the mechanisms behind resilience, empowerment, and salutogenic orientated strategies. Primary health care serves individuals as well as “aggregations of people linked by common goals” - our communities. Our communities, the building blocks of our society, display the bridge between the individual and the population. If the quality of our social relations, our feelings and meanings are prime determinants of our welfare and quality of life, then our communities are perfectly designed to learn more about this determinants and such about our health.
Health and illness are multidimensional phenomena embedded in the irreversible process of life. In this process, strong etiological causalities are the exception not the rule. To be successful, not only will more deliberate and creative approaches to causal inference in socio-epidemiological research be required, but also, interdisciplinary cooperation between various scientific disciplines (e.g. public health, general practice, neuroscience, immunology, epidemiology, psychology, sociology, genetics, molecular biology). Such cooperation will be crucial, to create a practical, scientifically sound and socially accepted model of health care at the interface of public health and general practice.
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