It feels like every day when I open my laptop, I’m bombarded by ads on google and social media promising a big health reward for little time investment. And even though I know from decades of working in global health that good health is a lifelong commitment and not a quick fix, I’m often lured into clicking on these links.. In many ways, that makes sense: it’s a reflection of our healthcare system, where the vast majority of doctors spend less than 15 minutes on average assessing their patients, and solutions to our health problems are prescriptions, tests, or treatment; rarely is the remedy long-term change in habit, nutrition or physical activity. 

Why is this important?  Because we spend billions –  no, trillions –  of dollars in our health systems focusing on short-term improvements for individuals and the population when what we need is a deeper dive into the concept of health and well-being  in our health systems. Perhaps instead of a pill or a 15 minute time slot each day to exercise, the solution might lie in learning how to pay attention to our body and mind, and the changes over time in our bodies and environments.

For the past 50 years I have been working on improving health systems. I started my career as a nurse and the tools I was provided with in nursing school were knowledge about the human bodily functions  (the heart, digestive tract, musculo-skeletal system and so forth)-   and how to help repair or maintain these during or after a sickness event.  What I was  taught in nursing school in the 1960’s is still important today: treating the person in a holistic manner and not just as a gallbladder surgery or a broken leg; providing a human being with dignity while caring for them when bodily functions were compromised; providing a soul with a supportive environment at the time of death; patiently listening and facilitating decision-making focused on the solutions the person had at hand and not my solutions for their problems.  But early on in my training I saw that in general my nursing education focused on sickness and not health and well-being.  I wondered if we couldn’t do better.

I saw some examples of people who understood my unease.   One was a cardiologist, let’s call him Dr. Strong,  a rather strange man, or so we student nurses thought at the time.  He jogged the 5 miles to the hospital, slowly chewed his way in the cafeteria through more vegetables than meat, strongly encouraged his patients to stop smoking before he would do cardiac surgery on them, spent time with his patients on strategies to lose weight or change their eating habits or calm their minds when they came to him following heart attacks.  His interest was in the person and their life as well as the specific cardiac medical care he was paid to provide. But he was, and I would say, still is an anomaly. Health professionals are taught to base their advice to patients on the best evidence they have to date.  In 1962, a United States Surgeon General’s report clearly demonstrated the causal link between tobacco and lung cancer, with the risk of disease decreasing when smoking ceases.  Despite this evidence  of the link between smoking and disease, a 1968 survey showed that  35.4% of the Canadian physicians surveyed still smoked cigarettes, with 25 % of those who had quit reporting their own individual respiratory health issues as the reason for quitting and not the research evidence.  

So why is it important to focus on improving health and well-being and not just medical treatments?  This difference is enshrined in the World Health Organization’s definition of health “… a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. Current health systems focus on repairing damage and not on prevention.  Basic risks such as diets based on sugar and fat, lack of routine exercise, insufficient or broken sleep, the dangers of not maintaining healthy relationships and overuse of stimulants (including smartphones and alcohol) are not the focus of 15-minute doctor’s visits.  Prescriptions handed out at the end of the doctor’s visit are for drugs or further tests, and the policy makers and insurance companies seem to be helpless in reversing the  disease focus in our health systems.  Possibly one  reason for this gap is that exercise, diet and relationships are seen as individual choices, doctors should not interfere, even when these health behaviors lead to damage and disease. This is even worse for women and minorities, given the well-documented gender bias in medical advice and treatment. Where women and people of color both do not have their ailments and pain taken seriously by doctors, and are often over-prescribed quick fixes for structural problems in the form of things like antidepressant prescriptions and referrals to mental health services.

Choice, individual choice, community choice, systems choice: sometimes history gives us examples to learn from.  There was a parallel event in 1962, when the Surgeon General’s report on the evidence against tobacco was published and the tobacco industry launched a million dollar, decade long campaign to fight the report through a variety of tactics, like buying off politicians massive advertising campaigns, and spending millions to discredit the science (the “Tobacco playbook” was so successful that it has since been used by oil and gas companies, the plastics industry, and the sugar industry to hide the undeniable harm of their products). The tobacco industry understood without a doubt the power that access to complete, unbiased information can have on our choices, which is probably why they worked so hard to obfuscate it.

Another example from 1962 of how our choices can be muddled by other interests is from the environmental movement.   Rachel Carson, a brave female scientist, made a radical proposal that, at times, technological progress is so fundamentally at odds with natural processes that it must be curtailed.  She was writing about the need to restrict the ever-increasing use of pesticides and their long-term negative effects on the environment, especially the insect population. These days, her work is acknowledged as one of the pillars of the current environmental movement, but at the time she was viciously attacked by business leaders, politicians and even scientists: among the labels given to her were communist, feminist, spinster, radical and alarmist. She also understood the power of unbiased and complete information “It is the public that is being asked to assume the risks that the insect controllers calculate,” She said. “The public must decide whether it wishes to continue on the present road, and it can do so only when in full possession of the facts.“ She understood that the ultimate solution to agricultural problems lay not in the quick fix of dousing the plants that humans consumed with agrochemicals, but rather in fixing our relationship to the natural world and our food system. 

So what is the lesson we can learn from this for our health systems?  I go back to Dr Strong, our cardiologist in 1968, he saw the need to influence individual choices being made by his patients, to provide them with information on leading healthy lives.  He was willing to dig deeper into evidence,  even if it was controversial and challenge the accepted practices of his fellow doctors.  He treated his patients holistically and not just as a heart attack to be placed on life-long pharmaceuticals or a heart surgery to remove cholesterol deposits (plaques) in the heart arteries.  Our current medical system is heavily influenced by research paid for by pharmaceutical and other technology firms, training of doctors and nurses still focus on treatment of disease and infirmity, and patients are left to make choices heavily influenced by  marketing of meat, milk and sugar.  Health systems await their Rachel Carson to lead our move away from a medical system focused on 15-minute treatments, quick fixes and pharmaceuticals to discussions about how to secure and maintain long-term health and well-being.