Fighting the diseases of want and plenty

A nurse takes someones blood pressure inside the East Arkansas Family Health Center in Lepanto, Arkansas, U.S., May 2, 2018. Picture taken May 2, 2018.    To match Special Report USA-HEALTHCARE/ARKANSAS     REUTERS/Karen Pulfer Focht - RC1C8E69F7C0
Editor's note:

This op-ed was originally published by Project Syndicate.

“Diseases of want” arise from poverty, while “diseases of plenty” are associated with affluence. Many of the illnesses in each category are avoidable, but stopping them will require a revolutionary change in our approach to medicine.

Diseases of want are avoidable because poverty is avoidable. We have the technical expertise to eliminate extreme poverty simply by sharing information, generating relevant skills, and redistributing a small fraction of economic resources. Our failure to overcome diseases of want thus reflects not a lack of knowledge, but rather a lack of will. And it is this unwillingness, not the diseases themselves, that we must address.

By contrast, diseases of plenty—such as obesity, tobacco-related illnesses, depression, diabetes, and various types of cancer—arise because our affluent lifestyles make us ill. Such illnesses also are avoidable, but again, we lack the will to conquer them. They occur because our approach to medicine is fundamentally wrong. Once we have understood this, we will be better able to tackle diseases of want as well.

The problem is that modern medicine focuses primarily on treatment rather than prevention. It is supposedly people’s right to live as they choose, and if they fall seriously ill, their health system—doctors, hospital managers, insurers, medical researchers, and many non-medical support staff—is meant to cure them.

If we took an equivalent approach to aviation safety, we would allow anyone to fly airplanes, with or without a license, and would not monitor safety equipment. If a plane crashed, aviation safety personnel would make every effort to save the injured, which would be expensive, given the gravity of the injuries.

Yet, in practice, aviation safety efforts concentrate almost entirely on preventing accidents in the first place. Aircraft are required to be serviced regularly. Weather information is readily available. Pilots and other aviation personnel receive rigorous formal safety training, and strictly enforced rules ensure that a pilot’s performance is not impeded by fatigue or alcohol. The industry has many other safeguards, most of which are implemented automatically.

Furthermore, all major aviation accidents are investigated by a national body whose reports are made public. Pilots are usually granted immunity from prosecution. And the aviation industry regards the safety of each passenger as equally important, regardless of what they paid for their respective tickets. Variations in ticket prices reflect differences in comfort and amenities, not in safety.

Now, suppose that we applied this aviation safety approach to medicine. Everyone would get regular, mandatory health checks, and have guaranteed access to information about healthy living. In addition, everyone would receive rigorous training in how to maintain their health, whether in school or at work. Rules for protecting one’s health would be strictly enforced, with automatic health safety checks at home, at work, and elsewhere.

At the same time, a national body would investigate all major diseases and publish its reports. Doctors, like pilots, would be immune from prosecution. Finally, the system would give equal attention to each person’s basic health, regardless of how much they paid for their health care. Different levels of individual spending on health would reflect differences in comfort and amenities, not in treatment.

In order to acquire a health-oriented mindset in medicine, rather than the ubiquitous view that medicine is meant to cure illness, it is useful to be guided by Detlev Ganten’s “health formula”: your health depends on your body’s biology, your environment, and your behavior.

Like most profound insights, Ganten’s formula sounds obvious once expressed. Crucially, it understands health as a state that is achieved when our behavior within our environment is adapted to our bodily needs. Thus, any behavior that makes our bodies maladaptive to our environment is unhealthy. And so is any environment, created through our lifestyles, that makes our behavior maladaptive to our bodies.

Once we take this health formula to heart, we see medicine with new eyes. For example, diabetes, high blood pressure, arteriosclerosis, arthritis, gout, heartburn, and gallstones, as well as cancer of the breast, intestine, and prostate, commonly arise from obesity and stress. Obesity often is a consequence of sedentary work and recreation habits, which result from the way we build our offices, schools, and cities. Thus, an important part of tackling diseases of plenty is for people to change their daily routines—such as by taking frequent brisk walks, playing sports regularly, sitting on appropriately designed chairs, and avoiding sugary foods.

Stress, meanwhile, frequently is caused by insecurity and disempowerment at work, unemployment, homelessness, or deficient social ties. Tackling this problem thus has implications for both government policy and companies’ strategy. For example, giving workers control over their daily work schedules, promoting cooperative work cultures, and mindfulness training at work could all reduce stress and contribute to public health.

Medications, doctors, and operating rooms still would play a role in such a health system, of course, but only after all the safety checks had been observed—just as ambulances have a function after a plane crash. Instead, we should focus mainly on how we conduct our lives, the example we set for family and friends, what we teach our children, and the physical and social contexts we create for our work and leisure activities. And although there also is a strong case for universal health care and an important role for government, this role lies primarily in prevention.

The same preventive approach would help the world’s poorest countries overcome diseases of want. Assistance to these countries should focus on eliminating extreme poverty and creating the social settings, habits, expectations, values, norms, and laws that promote health.

This is a new vision of medicine for rich and poor countries alike, where health systems still overwhelmingly concentrate on treating illnesses. By focusing instead on prevention, while adapting our environments and behaviors to our bodily needs, we can initiate a new age of medicine that enables us to overcome a host of avoidable diseases.