Ben Hoban lives and works in Exeter
It has been observed that people living in more affluent parts of the world with better healthcare and less disease tend to have a lower view of their health than people in poorer areas, where disease is more prevalent and healthcare less well-developed.1 Bizarre as this is, it may shine a light on some of our current difficulties.
For many globally today, as in previous generations in the UK, high maternal and infant mortality, an inadequate diet, fatal infectious diseases, violence and unsafe working and living conditions are facts of life. If you want to be healthier, the solution may not be within reach at the moment, but it isn’t complicated: find a reliable source of income or other help that will allow you to eat nutritious food, drink clean water and live somewhere safe with accessible healthcare for when you are ill, having children or in need of contraception. The factors limiting your health are all external, and a healthier life is an aspiration, something to move towards in a known direction. It isn’t easy, but it makes sense.
…for most people this is more about the impact of inequalities inherent in an affluent society than any absolute need…
In today’s UK, life by any objective measure is longer, safer and less burdened by disease than ever before. Health is still largely socially determined,2 but for most people this is more about the impact of inequalities inherent in an affluent society than any absolute need; we are more concerned about childhood obesity than protein-energy malnutrition, scurvy or rickets. Most of the patients we see are not in immediate danger: our role is usually to consider the possibility of a serious underlying cause of their symptoms, or to try to prevent serious illness in the future. We do this by investigating and by managing risk factors, acknowledging that while we are reducing the burden of disease in the population as a whole, the vast majority of individuals don’t benefit directly.
We accept health scares as the price of health.
For most of us, health has become something we’re used to having, but thanks to our tendency to loss aversion,3 something that we also fear disproportionately to lose. The threats to our health are more subtle and located within our own body now: disease is seen as something that could come at any moment with little or no warning, and from any direction. Patients and their doctors are responsible for being vigilant, reporting anything unexpected and taking what precautions they can, even though it may not help them. We accept health scares as the price of health.
We are indeed healthier than people elsewhere and in the past, but at a cost of much introspection, hypervigilance, and learned helplessness,4 or embodied paranoia.5 We are expending huge efforts to add further gains, pushing asymptotically towards a vision of perfect health, but perhaps it’s time to ask ourselves whether we would be helping our patients more by encouraging a greater confidence in the health they have already.
- Sen A, Health: perception versus observation, BMJ 2002; 324: 860-1
- The health gap: the challenge of an unequal world, Michael Marmot, Bloomsbury 2016
- Thinking, Fast and Slow, Daniel Kahneman, Penguin 2012
- Limits to Medicine: Medical Nemesis – The Expropriation of Health, Ivan Illich, Pub Marion Boyars, 1976
- The Wounded Storyteller, Arthur Franks, University of Chicago Press 2nd Ed 2013