What causes us to be well?
For most of us working in healthcare, this seems an odd question. Isn’t health caused by avoiding the causes of disease? Isn’t it caused by not smoking, not drinking too much alcohol, not becoming fat? Isn’t it true to say that that avoiding the causes of illness is the cause of health? And, if we do become ill, isn’t health is restored by rapid and effective treatment of disease?
There is no doubt that avoiding health damaging behaviours makes sense. However, the idea that health can be created is a proposition at least as sensible and as practical as simply avoiding disease. Many years ago, the World Health Organisation made a move in the direction of recognising health as a positive attribute when it defined health as a ”state of complete physical, mental and social wellbeing, not just the absence of disease or infirmity.”
The arguments for health creation – “salutogenesis” – have their origins in debates which stretch back 50 years. The problem is that they have not had nearly as much attention as the arguments for disease control. There are obvious reasons for this. Healthcare is an important driver of economic growth. It employs millions of people worldwide. There are strong vested interests in growing healthcare businesses. Health creation is not nearly so attractive as a business although the spiralling costs of healthcare in a time of demographic pressure from ageing populations make it essential that we find new and more sustainable ways to create health.
So, what is health creation?
Concepts of health creation have their origin in attempts to understand the reasons for the rapid growth in life expectancy that occurred in industrialised countries in the 20th century. In the middle of the last century, researchers began to try to explain the changing pattern of disease seen in developing countries. It became apparent that all societies go through three phases of health and disease as they modernize. In ancient times, when humans lived exclusively off the land, they experienced a phase of plagues and famine, during which mortality was high and life expectancy was not much more than 30 years.
With industrialization came a phase of “receding pandemics”, during which life expectancy rose from under 30 to about 50. The third phase in this transition arrived when technology was able, largely, to eradicate infectious disease as a major cause of premature death. Life expectancy increased rapidly and chronic disease affecting the elderly emerged to become the main health challenge This change from a high birth rate, high mortality society to one of low birth rate, low mortality and prolonged life expectancy has been described as the “epidemiological transition”. This is the phase that developed nations entered in the mid 20th century.
Was this transition due to better healthcare or social change?
This question was hotly debated during the latter part of the 20th century with some arguing that medical science, which had produced antibiotics, insulin and vaccines would produce the same kind of “magic bullets” to cure cancer and heart disease. Others weren’t so convinced. A significant proponent of the idea that social conditions create health was Thomas McKeown. He wrote a number of articles in the 1950s and 60s in which he considered the relative contributions of various factors to the decline in early mortality. He dismissed the importance of medical treatment, suggesting that a decline in mortality was obvious long before significant technological advances were introduced.
McKeown thought that “the rise of population was due primarily to the decline of mortality and the most important reason for the decline was an improvement in economic and social conditions.” McKeown also felt that one of the most important social factors contributing to the decline in mortality was improved diet.
McKeown’s dismissal of the importance of healthcare in improving health came at a time when real concerns were beginning to be expressed about the increasing costs of health services. A debate began as to the relative importance of improving health by making healthcare more effective or through greater attention to the social determinants of health. McKeown’s ideas came under intense scrutiny and some accused him of pursuing ideas based less on evidence than ideology.
In retrospect, it seems obvious that improving the effectiveness of healthcare and improving socioeconomic conditions in the population are both important for health. However, given that it is easier to research and measure the effectiveness of a defined treatment on an individual than it is to assess the effect of social change across a population, medical scientists have always had greater interest in healthcare research.
However, in the middle of this debate, alternative views as to the causes of wellbeing began to emerge. In 1966, Rene Dubos, a pathologist and ecologist wrote Man Adapting, a book in which he argued that health was not determined solely by exposure to adverse environments or disease causing organisms but was also influenced by the way in which individual humans respond to those challenges.
This idea was further developed by Aaron Antonovsky, an American sociologist and anthropologist, who argued that it is our response to external challenge which shapes the way we create health. He became interested in the importance of cultural tradition in creating stress. He posed the question: “what are the stressors in the lives of the poor that underlie the brute fact that, with regard to everything related to health, illness and patienthood, the poor are screwed?”
He embarked on a series of studies of the relationship between social circumstances and health in various cultural settings and with groups suffering from different illnesses, Eventually, he offered the suggestion that health creation was dependent on how effectively an individual had acquired the ability to make sense of and manage his place in the external environment. He suggested that, unless an individual had confidence that the world round about him was comprehensible, manageable and meaningful, the individual would experience a state of chronic stress. He described this view of the world as “having a sense of coherence”.
Many studies have now shown the relationship between stress and sense of coherence. Advances in understanding the biological consequences of stress show how it is linked to increased risk of many of the chronic illnesses which have emerged in modern society. Antonovsky’s analysis has strong biological as well as sociological evidence underpinning it.
By asking how health is created rather than dwelling on how disease can be prevented, Antonovsky offered a more rational and scientifically valid alternative to the healthcare/social determinants dichotomy. By conceptualising health as a spectrum with complete health (ease) at one end and complete lack of health (dis-ease) at the other, he offered a way to reconcile the two camps. In particular, his theories make it clear that, in the present state of human development, it is not sufficient to view the social determinants of health as simply those events that are external to the individual. Antonovsky made clear the crucial importance of the way the individual has learned to engage with external events as a key determinant of that person’s wellbeing. Much of the chronic disease we now deal with may be due not just to those external determinants but also to the way in which we respond to them.
This idea of the response of the individual to the world around him being critical to his ability to create health for himself eventually, led Huber and colleagues in the British Medical Journal in 2011, to suggest that “Just as environmental scientists describe the health of the earth as the capacity of a complex system to maintain a stable environment within a relatively narrow range, we propose the formulation of health as the ability to adapt and to self manage.”
So, what allows us to be adaptable and why might it involve coproduction?
The present paradigm of health, which sees healthcare as the prime agent of wellness, is driven by the needs of the individual. We assess needs and design services to meet those needs. Society responds by attempting to provide solutions and fix problems for people. In doing so, it makes the individual a passive recipient of services. He becomes disempowered. This disempowerment extends to whole communities who often find themselves the subject of planning and change determined in far away offices without adequate involvement of the citizens. The conventional approach of government often seems to be about doing things to people rather than doing things with them. If, as social theory suggests, a sense of control over one’s life is essential for wellbeing, this needs based approach, by undermining the individual’s sense of control and encouraging a passive response to policy, is far from helpful in creating wellbeing.
Recently, there has been a wide adoption in Scotland of asset based approaches to health and wellbeing. Asset Based Community Development (ABCD) is seen as a way of enhancing control by individuals and communities over their environment and the way in which they live their lives. The founder of this approach, Dr John McKnight suggests that: “Communities have never been built upon their deficiencies. Building communities has always depended on mobilising the capacity and assets of people and place.”
This way of working is entirely consistent with the salutogenic approach advocated by Antonovsky. However, what we learn from a consideration of salutogenic theory is that working solely with communities or solely with individuals will not be as effective as working at both levels simultaneously. Increasing the assets available within a community is a good thing but, at the same time, we need to recognise that those most in need of help are likely to be those whose capacities to become engaged in community development may be insufficiently formed to allow them to make use of new opportunities.
A critical aspect of the application of asset based development is the coproduction of outcomes as a means of giving individuals and communities control over their lives.
Professor Edgar Cahn, the Washington civil rights lawyer, was probably the first person to use the term in this sense.when he used it to describe what he called “the core economy.” He used it to explain how important neighbourhood level support systems are – families and communities – and how they can be built. Cahn recognised that this as economic activity, but it also functions as a means of enhancing control. Economists often describe it as the non-market economy. But the environmental economist Neva Goodwin instead describes it as the ‘core economy’. Ideas of co-production indicate ways in which we can rebuild and communities and realise their potential for creating wellbeing amongst their citizens.
What is coproduction?
Co-production, when delivered honestly and effectively, transforms the way systems and organisations potentially think about power and resources. It stimulates the growth of new partnerships and encourages people top think about taking risks to achieve aspirational outcomes, It is not a magic solution but requires integrity and hard work to deliver solutions.
In using coproduction techniques, citizens act as partners with agencies in designing and implementing change. As a result, both users and providers become empowered’. Citizens experience, perhaps for the first time, collaborative relationships with frontline staff who are able and confident to share power through acceptance of user expertise.
A vitally important aspect of coproduction is that it fundamentally recognises that citizens are not passive recipients of services and but have assets and expertise which they offer to others and which can help improve the way services are delivered.
Coproduction requires public agencies to do things differently. Often, there is a tendency for such agencies to adopt new language but carry on doing things as they have always done them. It will require the creation of new structures, new practices and realignment of financial streams if it is to become embedded as a long-term rather than ad hoc solution to social issues. Staff will require training but leadership and commitment from senior management is also essential if they are to appreciate the benefits of this approach. A critical part of the growth in understanding will be sharing stories of successes and failures in projects and programmes based on coproduction. Learning from international case studies of co-production while seeing how their lessons apply to local efforts is important.
The World Health Organisation has defined the social determinants of health as: “…the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”
With this definition, WHO nearly gets it right. The equitable distribution of resource is obviously essential in tackling inequality. However, redistribution of resource by itself will be less effective in narrowing inequality across the life course unless the social and cultural conditions is which people grow and develop allow them to develop a sense that their world is structured predictable and manageable. Coproduction in which citizens and public agencies exist as equal partners allows citizens to enhance their sense of self-management and control and supports the creation of wellness.
The English politician, Benjamin Disraeli said: “The greatest good you can do for another is not just to share your riches but to reveal to him his own.”
By involving citizens living in difficult circumstances in decisions made about their lives, public agencies have the opportunity to provide such gifts to their fellow citizens.
Sir Harry Burns
Chief Medical Officer for Scotland, United Kingdom /
Leiter der schottischen Gesundheitsbehörde, Grossbritannien
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