March 28th, 2011

Primary care—what it should embrace. A review of “A World of Health: Connecting People, Place and Planet”

By Larry Frolich and Alan Frolich

Everyone in the U.S. knows the ritual:  the primary care health visit. First, the phone call for an appointment several weeks in advance. On the anointed day, several pages of forms to be filled out across a high plastic counter-top.  Then the wait in a vinyl chair, a wall-mounted TV showing kids programs or cable news, the provider running at least 30 minutes late. Finally, the appointment begins with a call from a door beside the check-in counter:  “Mr. F______.”

A medical assistant documents weight, height, temperature, and blood pressure. A now-growing card-board folder is deposited into a plastic door-cubby, and after another 10 or more minutes a nurse enters and asks “the list,” in a fully non-committal fashion:  family health history, smoking, drinking, sexual habits and a number of mental-health indicators.  A recent addition to the ritual in the last five years has been the intense concentration on the computer screen as the answers are filled in.

Then, just as the questions end, as if choreographed, the provider waltzes in for the 20 minute annual allotment of “primary care” covered by your insurance company. The folder is reviewed, favorites from the list of questions are repeated, this time with empathy, a perfunctory exam is performed, and medications and test are ordered as indicated.   Finally, reflecting the more preventive philosophy that has permeated primary care medicine in recent years, the visit is closed with a number of relatively holistic concerns (which sometimes seem to change with the latest news):   “Everyone in the family wears a seat-belt all the time, right?”  “We’re cooking from scratch at home at least three times a week, is that true?”  “Get yourself a good bike helmet and wear it all the time.”  “Do you buy organic produce?  It’s a good idea.”  “And be sure to include a good source of Omega-3’s.”

This, only mildly caricaturized, is the state of the primary care ritual in America today.  And ritual it is, with science guiding parts (but by no means all) of it—a ritual not all that different in form and scope than those of so many other healing traditions, from Vedic medicine in South Asia, to acupuncture, to countless local herbalistic treatments, to Native American shamanistic ceremonies.  Read the “Body ritual among the Nacirema” (Miner, 1956) for a total revelation of U.S./Western-style health care practices dating back to the 1950’s.  It’s a great spoof, except that the only thing which is spoofed is the name of the tribe (read it backwards).  Otherwise the article is a perfect anthropologist’s view of how we arrange our health care, from the home medicine cabinet to the hospital surgery ward.

That the rituals of Western (or “Allopathic”) Medicine are powerful and bring incredible results in many instances cannot be denied.  What was life like before childhood vaccines?  Or antibiotics?  The ability of a trauma surgeon to put back together all the tubes and strings and sheets of tissue after a car-crash?  But without a doubt, the system has a giant weakness:  the entire process occurs with little and often token or ancillary regard for environment and lifestyle—for the larger social, ecological, economic context.  Of course there are “interventions” for these kinds of “problems” as well—via mental health referrals, social workers, life counselors, psychologists and psychiatrists.  But even then, all the focus is on the individual and their family, and what has gone wrong.  And it is always secondary, after the “problem is identified” in primary care.  But if “primary care” is to live up to all that those beautiful two words promise, then it must change, and it must come to include a full picture of an individual, embedded within a family, a home, a community, an eco-system, and even a world-wide web of virtual and digital connections.  This is the premise for “A World of Health:  Connecting People, Planet and Places.”

The book is, at its core, a highly informative collection of articles about people, the environment, and health.  The publisher, the Northwest Earth Institute, provides an enticing discussion-group-based framework for the articles, which are thematically organized into chapters, each of which addresses one of the key environmental factors that should be part of our “primary care.”  They envision the book being used as a guide to a series of weekly meetings where participants would undertake certain preparatory activities, discuss a number of provocative questions related to the topics, and conclude with some real actions that they can take.  In addition to being an informative resource, the book’s program holds the hope and promise of enabling people to make real changes in their lives—changes that could potentially improve their own health and the health of the world around them—changes that are outside the ken of our generally consumerist and nihilistic culture which encourages passivity and disregard for the consequences of actions or the possibility of alternatives.

The cynic haunting us wonders whether a book like this has a chance of reaching beyond those already convinced of its message.  But even for the choir, this hymnal may provide guidance and inspiration to make beneficial changes in their own lives, and even to begin reaching out to the community around them.   And the same cynic might doubt the utility of any countercultural effort, given the power of the corporate mass media and the entrenched political-economic forces—a skepticism that is exactly what those same powers might hope we embrace, and against which even the baby steps such as this book might foster are a necessary antidote.

One of us teaches Anatomy and Physiology to pre-health students for a living, the other practices medicine at a Veterans Administration hospital.   In our daily work, we encounter from different angles the ever-increasing list of individual health dilemmas that are found to be related to environmental factors.  Examples include osteoporosis, osteoarthritis, cardio-vascular disease, COPD (chronic obstructive pulmonary disease), asthma, diabetes, renal failure, cancers, immune breakdowns of all kinds, birth defects, infant mortality, childhood malnutrition (in “advanced” societies often linked paradoxically and perversely to obesity).

Many of these topics are treated in the first chapters of “A World of Health,” which describe a new approach to healthcare that has come to be called “ecological medicine” and has the following guiding principles as summarized by Kenny Ausubel on page 15:

  • The first goal of medicine is to establish the conditions for health and wholeness, thus preventing disease and illness.  The second goal is to cure.
  • The earth is also the physician’s client.  The patient under the physician’s care is one part of the earth.
  • Humans are part of a local eco-system.  Following the ecopsychological insight that a disturbed ecosystem can make people mentally ill, a disturbed ecosystem can surely make people physically ill.
  • Medicine should not add to the illnesses of humans or the planet.  Medical practices themselves should not damage other species of the ecosystem.

As the most important tool for implementing these principles Ausubel goes on to advocate general adoption of the “precautionary principle” as a replacement for the currently widely accepted “risk paradigm.” In short, the precautionary principle “argues that science and industry must fully assess the impact of their activities before they impose them upon the public and the environment.”  The basic premise of the risk paradigm is that “a certain amount of pollution and disease is just the price we have to pay for modern life” and places the burden on society to prove that new technologies and products are more harmful than beneficial—a burden of proof that is both exorbitantly expensive and often not possible before enormous harm has already been wrought (e.g, DDT, dioxin (Agent Orange), infant formula as a favorable alternative to breast feeding, greenhouse gases, to name just a few).

The precautionary principle provides a unifying theme for much of the book, and is illustrated with a multitude of examples from nutrition to household toxins to fossil fuels to consumption and consumerism.  None of this is new, and the path from small changes in individual habits to the necessary larger changes in the society and economy as whole is often unclear or a matter of wishful thinking at this point in time.  Yet the linkage between the larger environment and ecological frame, and the health of individual human beings, makes a powerful and provocative case, which brings new ammunition to a growing worldwide recognition of the need to do something to prevent further drift into ecological calamity.

In the classroom and the exam room, the two of us find it increasingly difficult to defend the efficacy of individual-based prescriptions for lifestyle maladies—again and again we cry out that the solution is based on better nutrition and more exercise.  But after decades of population-wide experiments with government-based nutrition recommendations, all kinds of nutrition counseling/education programs, and a myriad of training, exercise and physical education regimes, the fact is that lifestyle diseases are all on the rise.  The strength of “A World of Health” is that it analyzes, envisions, and proposes implementation steps for broad-scale, population-level changes that take us beyond the individualistic approaches that do not address the root of the problem.

If “A World of Health” leaves those of us teaching and practicing health care in the current system a little wanting, it is in the hope over time to show in practical terms how the important principles and approaches can be incorporated directly into the rituals of “primary” and subsequent care.  We hope that a next step will be in detail to show how sustainability issues could be brought into standard health care education and standard health care practice.  Because the reality is that the kinds of system-wide changes that the book advocates and foresees will have to happen (or at least begin) within what is currently functioning, albeit all-too-often dis-functioning.

In the inaugural edition of the Journal of Sustainability Education, Jill Manske (2010) breached the question of why sustainability issues are so frequently lacking in health care education.  Now, with this great response from the Northwest Earth Institute, we at least have an example of a provocative, well-conceived and stimulating discussion-based course with easy access to a wide variety of resources, to begin filling that gap.  If you are just casually interested in alternative ways to approach your own health care, you might find that this book opens a whole new way of thinking.  And if you are intimately involved in health care education, and have an interest in promoting sustainability issues, then this is a must-read and “must-use,” a first step towards bringing change into our lives and our work.

Miner, H. (1956).  “Body Ritual among the Nacirema.” The American Anthropologist, vol. 58 (1956), pp. 503-507.  Reproduced online:

Manske, J. (2010). First, Do No Harm: The Role of Sustainability in the Education of Health Professionals. Journal of Sustainability Education.

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