Sunday, August 25, 2013

Changing care: A shift in the global burden of disease - Carolien Van Embden Andres

International development and health are inextricably linked. One cannot talk about sustainable development without acknowledging the importance of health. This, I believe, most of us can agree on. Yet that is where the harmony ends. It is a jungle out there, in the field of global health. A jungle of ideas and solutions to a legion of health-related issues in a world that harbours so many different people, cultures and environments.

Many decision-makers take the concept of a jungle quite literal. Thinking about health in a global sense, there seems to be a traditional divide between the ‘’concrete jungle’’ that is the developed world and the ‘’real jungle’’ that is the developing world. Health-wise, the concrete jungle deals with chronic diseases (non-communicable diseases), whereas all the infectious agents that plague the ‘’real’’ jungle leave developing countries engaged in a combat against communicable diseases.
Yet, these ideas are very dated. Within the last decades, the global pattern of disease burden is shifting. Chronic diseases do not only affect the rich and the elderly, as commonly thought. In fact, most deaths from chronic disease now actually occur in developing countries. As their health systems are developed to address primarily acute problems, such as infectious diseases, chronic disease management becomes overshadowed and the issues inadequately dealt with.  

The biggest risk factors threatening our health today are blood pressure, tobacco, alcohol and poor diet; risk factors associated with chronic disease. The term ‘chronic’ conveys an important prospect: it means people will be spending more time living with disease. Simultaneously, cases of disability, whether due to disease or injury, will also spread exponentially. Although there is ample evidence available to provide a compelling argument in favour of the strengthening of health systems instead of solemnly targeting individual health areas and acute care, it seems donor-driven funding patterns do not allow this awareness to seep into the agendas of players in the field.
Without going into the power dynamics of money over policy there is a need for change. It is quite simple: changes in disease patterns means changes in care. We ought to be thinking about different approaches to health and healing. What does it mean to be living with disease/disability instead of merely suffering from it? What makes people crumble and what makes them cope?
Aaron Antonovsky, an American-Israeli sociologist, studied human resilience by looking into the cases of women that survived the Holocaust. Out of this group of women, only 29% appeared to be in good emotional health. Antonovsky was intrigued by how high this figure was, almost one third of women living through such a horrendous experience did actually have a positive outlook on life. This is what inspired him to formulate his sense of coherence theory.
People that have a strong sense of coherence during a difficult situation are able to comprehend, manage and derive meaning from troubling times. As such, they will experience less stress. And this is important. Stress is a major - if not one of the biggest - peril to health and healing. Reducing stress by having a strong sense of coherence can usually be prescribed to having understanding and perspective, resources and social capital. How a person is dealing with a disease will help shape its course.
Having a chronic affliction or a disability shakes the foundations of someone’s being. It changes the structures of daily life; our daily steps, habits and taken-for-granted certainties. As true as this may be for any disease, chronic conditions provide a much longer time-span to process these changes and learn to deal with them. During this process, social networks and institutions are relied on for support.
Diseases do not exist within a social vacuum. What causes disease to occur, spread and ultimately affect those involved is dependent on physical, psychological, social and environmental factors. Health care systems should therefore become more horizontal and integrative. Health issues are often interrelated; infectious diseases are entwined with chronic diseases. Some, such as HIV/AIDS are even hard to place under one banner, as therapeutic measures are increasingly becoming available worldwide.  We need health systems that are strong enough to accommodate a plethora of often unrelated health issues,, promote healing as well as coping, and that are open to wider social institutional involvement.  
Although this might seem a far stretch from what developing countries promptly need in terms of health care, shifting at least some of the focus towards building strong health care systems will be rewarded in the long haul. Surely initiatives to treat acute health problems remain relevant, as well as, for example, efforts to fight tobacco use and fast food intake. But if the focus is always on absence of disease and complete recovery, instead of the ability to cope with afflictions, we might overlook what is sometimes more important. In the end, the quality of health, as well as ill health, depends on the quality of care.

Carolien van Embden Andres has recently finished her Master’s programme in Medical Anthropology and Sociology at the University of Amsterdam.

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