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Before reading this article, ask yourself one fundamental question:
Who is responsible for your health?
It is this question that has split the realm of healthcare into two worlds for decades. On one hand, we have the Biomedical world, where the responsibility to treat and improve our illnesses lies entirely in the hands of healthcare professionals. Doctors, naturopaths, functional medicine doctors, alternative medicine practitioners, and the like.
Then there is the Biopsychosocial world, which posits that healthcare practitioners can help our health to a certain degree, but it is the collective onus of ours and our society to take care of ourselves and to create a socioeconomic atmosphere that is conducive to healing.
The healing journey does not end when you stop seeing your practitioner or taking medication – it begins at birth and ends at death. Health itself is treated as a spectrum, where a person moves between states of illness and wellness on a “health continuum”, instead of being unwell or well at one particular moment of time.
This seemingly logical argument has torn the world of healthcare in two because of one central factor: is illness only caused by external factors?
Let’s start by traveling back in time and looking at historical perceptions of illness.
Feeling ill? It’s probably demons.
Archaeologists have found skulls from the Neolithic period (10,000 BCE - 4,500 BCE) that have had holes drilled into them using stone tools, in a prehistoric surgical procedure we now call Trepanning or Trepanation.
It’s thought that the prehistoric humans of the stone age era would think of illnesses as the result of evil spirits being trapped inside their heads. This was also done to release pooled-up blood under the skull after a head injury due to hunting or falls, etc.(1)
Fast forward to the Ancient Greek era, and we distance ourselves from the idea of illness = evil spirits.
Hippocrates is now popularizing his theory of the 4 bodily fluids called humours – yellow bile, phlegm, black bile, and blood – which were influenced by the four elements of fire, water, earth, and air. The balance of these humours was thought to be regulated by conditions of hotness-coldness and dryness-wetness. It was believed that the balance or imbalance of these bodily fluids influenced a person’s health and temperament, and this theory of humourism became the crux of Western medicine for centuries. Eating foods that meet these categories of hot-cold/dry-wet and living in the right environment would affect one’s health.
Further developed by Galen, this theory led medical practitioners ranging from the ancient Greek era well into the medieval ages to associate mental symptoms such as anger, irrationality, depression, and other psychological problems as “illnesses”. Galen also associated the theory of bodily fluids with Plato’s theory of the tripartite soul, which stated that the soul is made up of 3 essential elements – spiritedness, wisdom, and desire.
In the Ayurvedic world as well, there was a similar theory of the Tridoshas (त्रिदोष) which stated that health was maintained by a balance of Vata, Pitta, and Kapha – the three doshas which corresponded with the elements of aether, fire, water, and earth.(2)
We come now to the Middle Ages.
In the Western world, religion was intertwined with the state, and dissecting the human body without explicit permission from a religious authority was banned. Medical knowledge (especially anatomy) had come to a standstill with the humoural theory having prevailed for 1400 years and practitioners having no way of actually looking inside a human body to find out what was going on.(3)
As a result, more and more people believed illnesses – especially seizures and mental illnesses – to be an act of the devil’s work. Their conventional forms of treatment (bloodletting, cupping, or leeching – based on the humoural theory) were deemed insufficient and treatment was often provided by monks who figured exorcism was the way to go. Treatment became a punishment; if you were ill, it meant you had lived a sinful life that let the devil in and now you must pay for it with your health. This was particularly so in the case of women’s health, as practitioners and monks alike took little to no interest in learning or even wanting to learn about this vital topic. Is someone behaving “oddly”? It’s probably demons. Burn the witch!(4, 5, 6)
[Unrelated (not-so) fun fact: Contrary to popular belief, both men and women were victims of witch-hunts, and execution styles were not limited to burning at the stake.
Exorcism of Holistic Healthcare
Yeah…it took a while, but healthcare eventually got back on track once “medical practitioners” stopped trying to exorcise illnesses out of people. Ultimately, Humourism was disproved in 1858 as the theory that microbes (germs) exist and could be causing illnesses gained more traction. The Ayurvedic Tridosha theory is still practised by many today. While the theory of bodily fluids may not be true in a literal sense, it brought attention to the fact that the world around us – especially the food that we eat – has a great impact on our health. This idea is now studied extensively in the field of Functional Medicine, where diet and lifestyle are used as primary treatments for diseases.
As Hippocrates rightly said, “Let food be thy medicine, and medicine be thy food.”
Long before modern medicine took over and wiped out any correlation of the world around us and our health, Galen had intertwined humourism with the Platonic concept of a tripartite soul, and this led to him achieving a greater understanding of the human body’s organs and systems. The Ancient Greek and Ancient Indian Ayurvedic theories of medicine correlated bodily fluids, natural elements, and a ‘soul’. This was, in its own way, an early holistic approach to health that was impeded only by the fact that the world lacked the fundamental understanding of anatomy as we know it today. We now know that it is blood that flows through veins, not air. But the correspondence of something in our bodies going wrong, causing something in our temperament or mental health to go wrong, based on the environment we live in, was an idea truly ahead of its time.(7, 8, 9, 10) The value of this core thought cannot be overestimated.
With the invention of the microscope and autopsies, as modern medicine took over, the holistic belief that the body and mind had anything to do with each other was ruled out, and in our opinion, this has dealt a significant blow to the progression of healthcare.
The Biomedical Model of Illness
The Biomedical Model of Illness is the basis of all modern medicine. It includes multiple factors, the most pertinent ones being that
- Health is the absence of illness;
- The mind and body have no relation whatsoever;
- Illness is only caused by pathoanatomical issues – stress and mental concerns cannot cause physiological changes in the body, and vice versa.
These postulates are where the biomedical model goes wrong.
The Biomedical Model states that all illnesses have a single, underlying cause (disease); reduces illness to processes of pathological interactions only, and health is achieved if the disease-causing agent is removed.(11)
It does not consider the impact of stress on the body. It ignores social and psychological processes which control the direct and indirect behaviours that can worsen or improve the health status of an individual. It prioritizes removing illness over maintaining health and does not consider that every individual has a unique body that requires unique treatment. It believes in a one-size-fits-all approach.
In summation, the Biomedical Model believes:
- What Causes Illness?
Pathogens and other disease-causing agents.
- What is the Relationship Between Mind and Body?
There is none.
- How should illness be treated?
Removal or management of the disease-causing agent through medication, and medical procedures that may or may not be invasive.
- Who is responsible for treatment?
Medical practitioners only.
- What is the relationship between health and illness?
Health is merely the absence of illness.
- What is the role of psychological factors in health and illness?
There is none.
It is plain to see how this model of illness does not deserve to be the basis of all modern healthcare, as it has been for the past century.
Stress to the Rescue! …Kind of?
It wasn’t until decades later, with advancements in medicine and psychology, that people began to notice correlations between increased mental stress and increased susceptibility to disease – especially chronic disease.(12) Prolonged periods of high stress with little to no control over one’s situation, and a lack of support systems demonstrated a physiological, observable effect on a person’s health. This focus on stress brought the world’s eye back to holistic approaches (finally).
A series of large-scale studies called the Whitehall Studies revealed that stress affects the heart rate, the neuroendocrine function, as well as the autonomous nervous system. These interactions could increase the risk of an individual’s likelihood of having a heart attack and developing other chronic diseases due to the high stress they experience on a regular basis. The lower the individual’s socioeconomic status, the higher the mortality rate from a wide range of diseases.
This study was conducted among British Civil Servants and it was found that they were more predisposed to chronic health issues than those who worked in superior positions, doing less work and in less stressful environments. It is thought that their higher social class and lower workload resulted in lower stress, which is why those in lower economic strata – working hard to earn money to subsist off of – were more likely to die of a heart attack than those who don’t need to work as hard to earn much more and live comfortably.(13) The behaviours of those in lower economic strata were also responsible for their health decline, such as smoking or alcohol consumption, which is driven by psychological factors.
In summation, the Whitehall Studies showed that social problems resulted in psychological stress which led to biological effects through nervous system responses and behaviors like smoking or drinking.
The Biopsychosocial Model of Health
The Biopsychosocial model of health was put forth by George Engel in 1977. It considers biological, psychological, and social factors as the determinants of an individual’s health outcomes. Most people will hear about the Biopsychosocial model in psychology, particularly in Health Psychology – which is a field concerned with how psychology affects health, and vice versa. But this approach to healthcare utterly deserves much more attention in the mainstream because of its valuable insights and holistic framework.
The Biopsychosocial model considers:
→ Biological Factors
Such as pathogens, lesions, disease
→ Psychological Factors
Such as behaviour, belief systems, coping mechanisms, stress, pain
→ Social Factors
Such as class, ethnicity, employment status, environment, gender, age
This model puts forth some very important points about Public Health and that we – as a collective society – need to improve the standards of living, the mental health crisis – and as a result, the biological health – of individuals. It suggests that psychosocial stress resulting from an individual’s living situation, such as workplace, workload, support system, socialization (or lack thereof), income, environment, and lifestyle factors like diet, exercise, substance abuse, etc., have an impact on his/her physical health, and not just pathogens or other agents of disease.
It is a useful framework or concept to consider when practicing healthcare, especially in the case of chronic diseases that often tend to have multiple root causes working together. These root causes are physiological issues, such as chronic inflammation, organ dysfunction, nutritional deficiencies, etc. But these root causes are themselves caused by other factors like diet, which is influenced by psychological health, which is influenced by social health.
This model also propagates the idea that for an individual to be truly healthy, they need to continue taking care of their health even outside of a professional healthcare space i.e., even when not seeking treatment from a professional.
The individual needs to recognize the kind of behaviours that are worsening their health and stop engaging in them, such as smoking, drinking, poor dietary habits, and thrill-seeking behaviours (rash driving, and self-harm in some cases).
The individual is responsible for their own behaviour and surroundings. It is our own responsibility to identify harmful and toxic situations, and then take the necessary steps to correct them for the sake of our health. Prolonged mental stress can manifest itself as physical problems through brain-body pathways. The Hypothalamic-Pituitary-Adrenal Axis (HPA) is one such example of a brain-body pathway that demonstrates the human stress response.(14) By handling our mental stress levels, we can help our bodies stay healthier.
In summation, contrary to the Biomedical Model of Illness, the Biopsychosocial Model of Health believes:
- What Causes Illness?
Various socio-environmental, psychological, and biological factors. - What is the relationship between the mind and body?
There is an intricate and co-dependent relationship. - How Should Illness Be Treated?
Illness and diseases require a holistic treatment that considers the physiological, mental, emotional, spiritual, and socioeconomic factors of the individual. - Who is Responsible for Treatment?
The responsibility for treatment is split between the individual themselves, the healthcare practitioner, and society. - What is the Relationship between Health and Illness?
Health and Illness exist on a spectrum of well-being, in a continuum of sorts. The individual transitions between states of healthiness and illness constantly throughout their lives. Health is not merely the absence of illness, and illness is not merely the absence of health. - What is the Role of Psychology in Health and Illness?
Psychology plays a significant role in contributing to both health and illness.
This model brings the main focus of healthcare back to the patient and goes back to a health approach where the effects of the mind on the body are not ignored. It is a far more inclusive framework, that can help to improve the mental health crisis that’s gripped the world for decades. The monster of chronic diseases continues its rampage unchecked, and one of the biggest reasons healthcare practitioners have failed to bring improvements is the huge ignorance of how socio-psychological factors affect our lives. Improvements in social qualities and living standards will inevitably bring about improvements in psychological well-being, which has an indubitable impact on our physical health.
Pigs to the Slaughter
At every level, since ancient times, the responsibility for treatment and healthcare has been in the hands of professionals who refused to acknowledge that what they believe in could possibly be erroneous. Often, conventional systems get so firmly set in place that even when budding new ideas that could bring about massive improvements do come up, they are invalidated and shut down due to the obstinate refusal to let go of convention. The result? The patients suffer at the hands of people who refuse to let go of tradition and problematic belief systems.
Those deeply rooted in the system cannot realize that the system is problematic.
How can something that’s been the norm for centuries be wrong? Well, it can. Scientific thought is built on the foundation of questioning beliefs and proving and disproving theories. Man is a fledgling in the cosmos, learning about everything as he goes along.
And historically, this realization has come at a costly price –
Handwashing: The Inspiring Tragedy of Challenging Medical Norms(15)
Hungary, 1840s: Ignaz Semmelweiss and other doctors are noticing a worrying increase in the mortality of new mothers. They performed multiple autopsies to investigate, but found no relevant answers. The next day, they would help more mothers deliver babies, only for those mothers to pass away. This fatal sickness was called “childbed fever”, or puerperal fever. Doctors did not know how to help young mothers avoid this death sentence.
When Ignaz Semmelweiss – now known as the “saviour of mothers” – told the doctors that the prevailing system of patient care was the reason dozens of new mothers were dying, the entire medical industry ostracized him.
Semmelweiss had immersed himself in the study of this fever and noticed that doctors, after performing autopsies on patients who died of childbed fever, would perform child deliveries the next day. He theorized that disease-causing microbes are spreading from patients to doctors, and from doctors to new patients. He suggested that doctors should wash their hands with a chlorinated lime solution in between and after patient care.
His idea was considered outrageous. How could these esteemed doctors with years of experience in medicine be the cause of patient death?
The medical industry refused to give any credit to his ideas. His peers rejected him, and he lost his medical license. He was kicked out of his field, while doctors continued to tend to patients without disinfecting themselves, causing more deaths.
Semmelweiss succumbed to the pressure of society’s rejections and lost his mind. He was admitted to an asylum, where he eventually lost his life. He did not have the opportunity to learn that he was right, and centuries later, the world of patient care now revolves around his crucial discovery.
“When I look back upon the past, I can only dispel the sadness which falls upon me by gazing into that happy future when the infection will be banished...The conviction that such a time must inevitably sooner or later arrive will cheer my dying hour.”
– Semmelweiss.
Upending Healthcare, Functionally
The current world of healthcare needs a revolution. It is based on century-old beliefs that deprive us of the healthcare we deserve. By the time errors are discovered and fixed, it is usually too late. It takes a disaster for those in the system to learn that the system is faulty.
The Biomedical Model needs to be integrated with the Biopsychosocial Model to create a new model of healthcare, where unique patients receive unique treatments, on a holistic level that considers their sociological, psychological, and biological factors. The patient-practitioner relationship needs to be personalized for the best results.
We are hopeful that as knowledge becomes more easily accessible, as developments are made in the fields of medicine and psychology, the developments yet to come will hold great promise for those of us who will be at the receiving end of treatment. And we are excited to see the start of a beautiful health-revolution where everyone comes out happy, healthy, and thriving.
References:
- Ancient Legacy of Cranial Surgery - PMC
- A glimpse of Ayurveda – The forgotten history and principles of Indian traditional medicine - PMC
- History of the Autopsy | Mopec
- Medicine in the Middle Ages | Essay | The Metropolitan Museum of Art | Heilbrunn Timeline of Art History
- Demons and Mental Disorder in Late Medieval Medicine in
- Dealing with Devil Has Long Been a Part of Medicine | MPIWG
- The Ancient World - the Four Humors in Relation to the Four Elements - LabCE.com, Laboratory Continuing Education
- Galen: On Blood, the Pulse, and the Arteries
- Humour | Humorism, Hippocrates, Galen | Britannica
- Humoral Theory | Contagion
- Do biomedical models of illness make for good healthcare systems? - PMC
- Mind–body research moves towards the mainstream - PMC
- Health inequalities among British civil servants: the Whitehall II study - The Lancet
- The role of the hypothalamic-pituitary-adrenal axis in neuroendocrine responses to stress - PMC
- Semmelweis' Germ Theory - The Introduction of Hand Washing
Other references:
- Biopsychosocial Model of Healthcare
- Biopsychosocial model of illnesses in primary care: A hermeneutic literature review - PMC
