Heroes Not Zombies

This is one in a series of articles about health. There’s an almost unspoken belief that the way to make people healthier is through Medicine, and the Health Services through which Medicine is delivered. I’m not sure that’s true. Some of the most striking improvements in population health throughout history have come through the provision of clean water, effective sewage systems, and making such changes as housing the population in better houses, reducing malnutrition, and tackling poverty.
I think it’s important to deliver good health care, and, for me, that means both adequately resourced health care, and, perhaps more importantly, human-scale health care.
What do I mean by that?
Health care where the day to day, hour by hour, minute by minute focus is what human beings do together. It’s caring, compassionate, staff who are well educated in engaged and committed relationships with those who are suffering.
But one thing is clear. The demand for health care is increasing, and shows no sign of tailing off. The higher demands rushing fast down the pipeline come from demographic change with many more people reaching old age, and, consequently, many more with chronic illnesses, complex needs and, ultimately a requirement for good, end of life care before they die.
If we want to tackle the rising demand, we have to deal with the causes of ill health, and if we restrict our focus to individual behaviours, we’re going to fail. We have to deal with the economic, social, and environmental causes of ill health if we want people to live more of their lives in good health.
I’ve written about housing and food so far, and here I’d like to explore education.
Some people claim that education is THE most powerful way to make an impact on population health and it’s a hard claim to refute. Education can improve health in many, many ways, some more obvious than others.
For example, education can reduce poverty and improve incomes, enabling people to find more adequate shelter and to eat more nourishing diets. Education is particularly effective when focused on women and girls. Educated girls and women tend to be healthier, have fewer children, earn more income and provide better health care for themselves and their future children. It reduces maternal deaths and helps to combat infectious diseases, including HIV and AIDS.
Did you know that a child whose mother can read is 50% more likely to live past the age of five?

Don’t you think that’s stunning?
If you want to explore this further have a look at the United Nations 17 Sustainable Development Goals.
But there is another aspect to education I’d also like to consider. It’s the education embedded in the ordinary doctor-patient consultation. Or at least, it could be. One of the first tasks of a doctor is to make a diagnosis, which is a way of saying to arrive at an understanding. The doctor tries to make sense of the patient’s story, of their symptoms and of the signs of disease in their bodies. A diagnosis unlocks the door to effective treatment, and by effective treatment I mean whatever encourages a restoration of health (though, sadly, many treatments don’t do that, they just either maintain the status quo, or slow the progression of the illness, but with less suffering).
Why shouldn’t diagnosis be a shared experience? Not just a label applied by the professional. One of my favourite diagnoses to illustrate this labelling behaviour is “Idiopathic Urticarial Syndrome”. A patient goes to the skin specialist with an itchy rash. They don’t know why they’ve got it. They don’t know what it is. But the skin specialist does. It’s “Idiopathic Urticarial Syndrome”. Well, here’s a secret. “Urticarial” means an itchy rash (OK, it’s a particular kind of itchy rash, one with “weals”, which is another word for “urticaria”). “Idiopathic” means in this particular case we don’t know what is causing it. If we knew what was causing it, it wouldn’t be idiopathic. It’d be an allergy to washing powder or whatever. “Syndrome” is a trick word. It’s sounds like the name of a disease but actually it’s a collective word for a group of symptoms (and maybe some signs). So, having sought help with an itchy, urticarial, rash whose origin is unknown to you and which you don’t understand, you now know you have an itchy, urticarial rash, whose origin nobody knows, and which nobody actually understands.

There is a different way.

Rather than seeing a diagnosis as an end point, it I can be thought of as a level of understanding. Then the doctor can take it as a step forwards, not a job done. A step towards a better, deeper, broader understanding of the patient. They can explore some of the mystery, the when, where and even the why of the illness. I think this is a form of education. It’s the doctor educating themselves about this particular patient.
An exploration of the circumstances of an illness, probing the when, the where and the possible why questions, is an opportunity for education for the patient too.
If somebody understands better what is going on, and what the initiating and maintaining factors might be, they can make other choices. Choices which might well lead to restoration of health.
One of my most favourite questions in a consultation was to ask the patient when they last felt completely well. It might take a bit of encouragement to get there, but most people can identify the period of their lives before this illness began. Having identified the time around the change from health to illness, I’d then explore what was happening in the patient’s life around that time.
I can’t tell you how many times that was like a light bulb going on. “Do you think my mother’s death might have had something to do with getting ill?” “Do you think losing my job, getting divorced and the death of my brother all in the same month might have had something to do with this?”
Of course, I could never answer a simple yes. It was just a helpful way to begin to explore the potential factors, their impacts, and what someone could do to tackle the ongoing effects.
I’m sure this isn’t possible in every single encounter, but it’s something to bear in mind. Ideally, all doctor-patient consultations can be therapeutic ones, and perhaps the best way for them to be therapeutic is when both the doctor and the patient learns something from the experience.
Learning from experience is definitely a powerful education.

One of my friends says “If everything that goes wrong is a learning experience I’d have a bloody PhD by now!”