Our current U.S. medical system doesn’t work. It is not able to adequately care for the sickest, most vulnerable, and least resourced people. It often excludes those seen as “other” in our society. To become a just system, we need a new focus on Whole Person Health (WPH). Very briefly, WPH cares for the whole person and considers how individual, community and societal factors influence health.
In this first blog of a two-part series, we discuss why our current health system will never be equitable without adopting a WPH model as an alternative approach. The second part reviews the details of what WPH entails.
A narrow focus on symptoms rather than people
As Paul Farmer and colleagues explained, clinical medicine doesn’t consider or address root causes of disease beyond the biologic. It ignores built-in factors in medicine and society that continue the pattern of poor health outcomes for oppressed populations.
Many peoples’ health and social needs go unmet. So, many people are getting sicker, and some health disparities are growing. The pandemic magnified health inequities for black, indigenous and other people of color (BIPOC), who already do worse than their white peers in many areas of health.
We currently train our doctors and other health care providers to treat body parts and diagnoses instead of whole people. Doctors are rewarded financially (and with status) for becoming specialists, focusing on smaller and smaller parts of the body. We see patients in sterile offices, without family, community, and cultural contexts.
Current funding is mismatched with the causes of disease
What we have now is sick care. Preventive or wellness visits focus mostly on finding existing problems like cancer and heart disease, not true prevention. This leads to expensive tests and referrals, which results in medications or procedures that target a single symptom instead of the whole person. Chasing symptoms contributes to the top 5% of the sickest individuals accounting for half of all medical costs.
We ignore the fact that humans are complex beings who exist within multiple other systems. Most of what affects health and healing is beyond a person’s individual control. We know that social, environmental, and behavioral factors have the largest influence on our health. Studies show, for example, that people who live in marginalized neighborhoods are more likely to be in poor health.
Getting to health equity also requires understanding the underlying causes of disease, including allostatic load (the additive effect of chronic stress). Long periods of toxic stress may create inflammatory, neurohormonal and epigenetic changes that may contribute to the development of disease. For example, the typical explanation of heart disease focuses on cholesterol and lack of exercise, but ignores the role of the social determinants of health (SDoH) and allostatic load. Yet, a study of over 22,000 participants over 10 years and found as the number of SDoH issues increased (and presumably allostatic load), so did the risk of heart disease.
There are many new approaches to addressing social determinants of health (SDoH) and health equity in communities. Many settings are now doing SDoH screening and social care referral platforms can help connect people to social care services. Such programs are necessary, but only receive a small fraction of the funding allocated within the medical care industry.
We need a much wider view of the determinants of health
Focusing on unmet social needs is only part of the solution. Another factor that leads to health inequity is implicit bias – unconscious responses to people seen as “other”. We need to look at how these biases influence the medical care system. Medicine often looks at patients as a set of symptoms or stereotypes drawn from our biases. Instead, we need to shift the mindset and treat patients as individual, whole people.
The medical system needs to approach patients as empowered drivers of their own health. They are not passive victims of illness. Taking into account all the factors influencing health and healing -social, environmental, lifestyle, behavioral, emotional, physical and spiritual – can turn conventional medical care into a health-building experience. WPH widens the lens to let us see these factors.
Stop blaming and look at the whole picture
We need to rethink all clinical interactions once we understand the broader causes of disease. Doctors often approach lifestyle and behavioral change with the assumption that poor health is the patient’s fault. When a patient is obese or has an uncontrolled disease, we imply that it’s because they didn’t make the changes in diet or exercise we recommended. We ignore factors like unsafe neighborhoods or that modern society is rigged against health. Poor quality processed foods, starches, and sweets fill a family’s stomach for much less money than fruits and vegetables.
Yet most patients feel they are unhealthy because of their own lack of willpower or efforts. The implied judgment in medical interactions leads us further and further away from true health equity – the chance for all people to be truly well, not just free of disease. A compassionate approach can replace the scolding tone often felt by patients. When everyone inside and outside the medical system understands the impact of factors beyond a person’s control, we can look at all the challenges to their health.
The potential of Whole Person Health
WPH is a relationship-based approach that helps individuals take control of their health. WPH can equalize the power imbalance that exists between a patient and a doctor. It encourages providers to take a proactive approach, partnering with patients to help them stay healthy. This can replace the current reactive approach where we wait for people to come to see us with a symptom or a “chief complaint”.
Instead, WPH centers the visit on “what matters” to a person, instead of “what is the matter?” It can help providers bear witness to the downstream effects of trauma, stress, and environment, and then help work to mitigate those. The social drivers of health become part of the dialogue with each person. It may also help promote resilience by honoring a person’s values, beliefs, and abilities. A recent Medical Care blog post introduced the concept of measuring and centering palliative care on what matters to patients and families. Why wait until people are so ill to use to take this perspective on their health? WPH uses this approach with all people at all stages of life.
Meanwhile, the health system itself can continue work on community engagement, advocacy, and policy. Some health systems are focusing more on WPH and demonstrating that this approach is viable. As an example, the U.S. Department of Veterans Affairs has successfully piloted a WPH initiative called Whole Health at 18 sites, and is expanding implementation. A related approach in South Central Alaska’s Nuka System of Care, similarly shows that change is possible and effective.
Small reform steps are not enough
Attaining health equity requires a dramatic shift in health care, and it can be done. Our current model does not address underlying causes of disease beyond the biologic, ignoring the largest influences on health. SDoH and systemic bias must be explicitly considered and addressed. The system needs to work on ways to relieve the toxic stress it produces. Small steps to reform are not enough.
Please stay tuned for Part 2 of our series on WPH and how it can help achieve health equity.
Elena Rosenbaum
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Marva Richards
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Andrea Gordon