Live well, live long: Medicine turns focus to well-being
■ A leading public health expert says a third era of health care has begun that emphasizes on improving quality of life rather than just increasing its length.
By Victoria Stagg Elliott — Posted Aug. 21, 2006
Wayne Reynolds, DO, a family physician in Newport News, Va., has never seen a case of measles and can't remember the last time he diagnosed chicken pox. Both infectious diseases were leading causes of death a hundred years ago.
Of course, acute illnesses are still a frequent focus of patient visits in his practice. But he also spends a great deal of time delivering preventive health care. And he increasingly finds himself treating conditions affecting his patients' quality of life.
"I'm seeing people take a more proactive role in their health," said Dr. Reynolds. "And I do probably see more patients in 2006 for [erectile dysfunction], incontinence and menopause. It's quality of life."
This pattern represents the practice of medicine in the beginning of the third era, or revolution, of health, said Lester Breslow, MD, MPH, ScD, professor emeritus of health services and dean emeritus of the School of Public Health at the University of California, Los Angeles,
Embracing the new era
The first era, which ran from the beginning of medicine to approximately the middle of the 20th century, focused on battling infectious diseases, which were the leading health threats.
In the 1950s, after many infectious diseases were wrestled into control and people started to live longer, the focus slowly shifted to the chronic diseases. Dr. Breslow, a former director of the California Dept. of Health Services, was one of the first public health officials to work on chronic disease as a serious public health issue.
Now, he has suggested in a series of recent journal editorials, that, with significant progress having been made against chronic conditions, the third era has begun. This health epoch, he says, will focus on improving quality and function in life.
"People are living longer, and they're living really quite healthily. I don't want to denigrate the importance of still tackling the communicable and the chronic diseases, but we now can begin to have a different view of health," said Dr. Breslow, who, at age 91, is still referred to as "Mr. Public Health" in deference to his long career in this field.
In Dr. Breslow's opinion, the focus of medicine and public health must expand not just to prevent death but also to maintain patients' optimal functional capacity.
"Now that we don't have to devote all of our resources to the fatal or highly acute diseases, we can begin to take note of how we can improve health by defining impairments of health," he said.
According to his theory, health in the third era involves more than just keeping blood pressure, cholesterol and body mass index, among other health indicators, out of the danger zone. It will increasingly involve working to keep these indicators in the ranges needed for optimal performance. It's not about repairing people after they are damaged by disease but doing everything possible to prevent that disease from ever occurring.
Similarly, children's health care will require more than providing necessary immunizations and intervening when young patients are ill or injured, but also guiding their intellectual, emotional and physical development.
"Medicine is moving into it quite definitively," said Dr. Breslow. "[Physicians] are beginning to guide health. What we need to do is simply expand that role. People want more preventive medicine, and what they want is not just to prevent flu or pneumonia but to gain a reserve of health so they can do what they want to do."
Figuring it all out
Experts agree that much of what Dr. Breslow envisions for this third era is well under way.
"He's talking about this whole issue of a transformation from this concept of sickness care to ensuring health," said Georges Benjamin, MD, executive director of the American Public Health Assn.
Physicians are now faced with a significant number of patients surviving diseases that used to be fatal. These patients expect to live well -- not just longer. Many also seek to avoid symptoms of numerous conditions such as menopause, sexual dysfunction and cognitive impairment that formerly were viewed as a normal part of aging.
"People are expecting that they're not going to have these kinds of disabilities that have long been thought to be part and parcel of old age," said Patrick Tranmer, MD, MPH, chair of the Dept. of Family Medicine at the University of Illinois, Chicago. "We don't want to live with pain. We don't want to live with reduced activities of daily living. We don't want to live with any sort of mental defect that will impair our ability to enjoy life."
The idea of a third era of health is not a completely new concept. It has been a long-stated goal of several public health bodies. Most notably, in 1948, the World Health Organization defined health as "physical, mental and social well-being, not merely the absence of disease and infirmity." Dr. Breslow has been in the lead, however, in declaring the third era already under way.
"It's not a brand-new idea by any means. I've been struggling with it and a lot of other people have for 50 years," said Dr. Breslow.
And many public health officials have high hopes that this third era will continue to develop and translate to even further improvements in health. They also foresee it resulting in a reapportionment of health care dollars from treatment and end-of-life care to prevention and interventions that improve life at earlier stages.
"If you think about the potential outcomes of such a profound concept, it could dramatically [alter] what we pay for and what we invest in," said Dr. Benjamin.
But as the new era becomes more of a reality, it is also generating concerns. The biggest question is how to determine success, which was measured in the first and second eras by reductions in deaths. Dr. Breslow has focused much of his work on finding a solution to this problem.
"We have the quantitative aspects of health in the first two eras. It seems to me that we need [measurements] for the third era. First, to define it and then measure progress in it," he said.
For instance, because the concept of quality is difficult to grasp, many experts are concerned that health care costs will get out of control as patients demand even more interventions.
"We may not be able to afford all of these interventions and screenings and preventive activities for all people," said Dr. Tranmer. "We're already stressed with our ability to provide medical care to most people for the issues related to the first and second eras."
This challenge is particularly great because many of the lifestyle interventions patients are now asking for are in part driven by marketing from pharmaceutical companies, hospitals and health care professionals.
"We do great things, no question about it, and people live longer. But we do it with the help or with the distraction of a lot of direct-to-consumer advertising from insurance companies and from doctors. Why does a hospital have to advertise? Does that add a minute of care or benefit to society? No. It's marketing, and it's big business," said Larry Anderson, MD, a family physician in Wellington, Kan.
Concerns also surround the equitable distribution of health resources.
"We have failed as a world and failed as a country to bring everybody up to the third revolution. This has been a revolution where many have been left behind," said Jeff Susman, MD, chair of the family medicine department at the University of Cincinnati. "It's unfortunate that there are many people, probably in each and every one of our communities, who have been left behind."
Also, while patient expectations are, in part, driving this shift into the third era, experts also worry about how to motivate patients to be more involved in their own health. Achieving this objective will be difficult. And, whereas the first era focused on infectious diseases that may have lasted days or weeks and the second era focused on chronic conditions that lasted years, the third era focuses on maintaining health over a person's entire life. Patients need not only to be involved, but to be involved for a very long time.
"The medical establishment as a whole has yet to figure out how to effectively change lifestyle," said William Branch, MD, director of general internal medicine at Emory University in Atlanta.
Physicians also note that, even as health care transitions into a third era, the first- or second-era problems that still exist cannot be neglected. Infectious disease is no longer the leading killer but it's still in the top 10. Outbreaks of novel agents such as SARS or pandemic flu often seem to be imminent. Also, conditions such as cancer and heart disease remain big problems, while other diseases, such as diabetes, are growing as threats.
"We have the 85-year-old marathon runners, but, for the most part, we're heavier and less physically fit than we were decades ago," said Dr. Anderson. "We can improve your cholesterol values, and we can improve your blood sugar values. But, unfortunately, we have so many more diabetics than we used to."