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Gross National Health

David Rakel and Michael T. Hernke

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

                              -The World Health Organization- 

A key challenge of health care reform is that there is significant financial investment in the treatment of disease. The rising disparity between medical cost and quality is demanding that the focus be changed. As America explores new models of delivery, it is important to ask, what is our primary intention? Is it a continued focus downstream on disease management or is it truly health?  

America has a profit driven medical system that has disease care as its primary product. Since disease is what brings profit, it directs the energy and talent of the medical system. Currently, disease care guides medical education, hospital growth and drug development, but provides little financial incentive to avoid disease or to achieve health. In fact, if we can help our patients adopt lifestyle behaviors that result in health, profits decline because health is not the product that brings value to the current medical model. Walter Willett, a Harvard nutrition expert reports that 65% of chronic disease could be prevented with improved nutrition. Imagine a health care system that first focuses upstream on creating health for its constituents. Our current medical system does little to honor the term "health care." 

Consider the country of Bhutan that has organized their whole government around the intention of creating happiness for its citizens. A New York Times interview quoted Lyonpo Jigmi Thinley, Bhutan's home minister and ex-prime minister as saying, "We have to think of human well-being in broader terms. Material well-being is only one component. That doesn't ensure that you're at peace with your environment and in harmony with each other." When a nation focuses only on growing the monetary value of its output (Gross National Product, GNP), this intention can actually sacrifice the health and well-being of its people. For example, economic activities that are priced equally can differ in their costs to society. Think of a dollar's worth of broccoli and a dollar's worth of a processed pastry rich in trans-fatty acids. Both can have similar economic rewards, but one has health benefits and the other can contribute to disease growth. 


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Currently America's health care system has a similar concern. Human disease and its treatment is what gets measured, taught, reimbursed and researched. Our "health" care system honors Gross National Disease (GND). Imagine if our political, business and health care leaders could agree that the most important outcome that our nation could invest in were the health of its people. What teams of professionals would need to work together for success? How would we reimburse for health creation? We could answer these questions if our main intention were to create "Gross National Health (GNH)."   

To deliver the value of health, we need to create a climate conducive to growing systems of health care. If we can financially incentivize health, talented people will be called to achieve it.  

For GNH to be successful, we would first ask what is right with people and help it grow before asking what is wrong with them and try to suppress symptoms with medical technology. When disease care is the product, we often treat dis-ease with drugs. For example, if a patient comes in for upper abdominal pain, the current medical culture supports prescribing a drug that significantly reduces acid in the stomach to improve symptoms. The clinician can do this in 5 minutes which is economically supported by being able to see more patients and encouraging dependence on a product that supports a large industry that puts food on the table for many of its employees (pharmaceutical industry). This focus distracts the clinician from taking the time to listen to the story of the patient to find out about their nutritional habits or what's "eating them up inside." It also increases side effects from long-term acid suppression when acid is needed to absorb iron, calcium and B-vitamins. The end result focuses on symptom suppression, not symptom resolution. Investing in health and disease are both important but are currently out of balance. Ninety-Five percent of our health care dollar is spent diagnosing and treating disease. However, the greatest influence on major diseases is not intervention with medical technology but prevention via human behaviors such as not smoking, improving nutrition, regular exercise and stress reduction. Health is not about what we take, it is about what we do.

  What would a health care system that has Gross National Health as its primary intent look like? How could we make delivery of health a viable business? As with many movements, public awareness is shaping government policy. People are realizing that happiness and health do not always come in a pill, but in the form of human relationships, movement, whole food and spiritual meaning. As the public demands access to a health care system that provides proactive health benefits, the demand for fitness trainers, nutritionists, psychologists and spiritual guides will go up while reducing our nation's dependence on ‘happiness in a pill.' Technology and medicines are important ingredients to health. Currently technology has overpowered the importance of the person's story and the opportunity to tell it to a clinician who has time to listen. What if our medical care system helped people come off medicines instead of primarily prescribing them? The irony is that the business of health is currently in stark contrast to the business of disease. This can change if we work together and create a shift to have health as our primary intent. 

David Rakel, MD, is on the faculty of the University of Wisconsin School of Medicine and Public Health, Dept of Family Medicine. Michael T. Hernke, PhD is on the faculty of the University of Wisconsin-Madison School of Business.

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