In medicine, we focus a lot on preventing, diagnosing and treating diseases. But we also know, at an epidemiological level, that good health doesn’t start in the medical clinic. The major predictors of good health outcomes are economic, as well as social; they have to do with whether people have social support and live in safe neighborhoods, whether they have safety net systems to maintain good nutrition in times of distress, or whether they revert to drugs and alcohol in bad times. These factors seem to predict health outcomes better than access to good medical care or medications. In this week’s post, we talk about a new set of initiatives spearheaded by the Robert Wood Johnson Foundation that attempts to capture these ideas into a new model for healthcare delivery.
After the fall of the Soviet Union in the mid-1990’s, about 40 million Russian men suddenly went missing. They didn’t emigrate from Russia to other countries; they also hadn’t been killed in border zone fights or “disappeared” by army troops. They had died rather suddenly, generally from alcohol-related deaths and heart disease. Most of them were young, of working age, and single. And in a series of subsequent studies, it was found that these men were generally dying of a “broken heart” so-to-speak–without prospects for good jobs or the capacity to raise a family, the loss of income and pride and future prospects in the context of a massive change in the economy left them with little but vodka. They died from alcohol-related cirrhosis, suicides and heart attacks. This may seem a little fruity to hard-nosed scientists, but now we see similar trends among patients who are suffering in the current recession–not only from explicit mental health problems after foreclosures and job losses, but also from cardiac, hypertensive and nutritional consequences of “giving up” on their health (eating poorly, not taking medicines, etc) after facing the sheer devastation of losing their homes and jobs.
According to Martin Seligman, director of the Positive Psychology Center at the University of Pennsylvania (and the guy who invented the term “learned helplessness” that medical workers in budget-constrained clinics are all-too familiar with), there is a new emphasis on “Positive Health” that seems to encompasses the understanding that these psychological and social factors really matter to health outcomes–that “people desire well-being in its own right and they desire it above and beyond the relief of their suffering.”
The goal of this initiative is first to identify clearly–at both an epidemiological and personal level–what good “health assets” are for patients in specific contexts–whether that be assets like having a set of family members to put a roof over a patient’s head after a foreclosure, or assets like having some bank account savings to buffer the cost of prescription co-payments after the loss of health insurance, or assets like having a cheap grocery store in the neighborhood to maintain good nutrition in spite of having a thin wallet. These assets are associated with a healthier and longer life, lower health care costs, and better prognosis when illness strikes. The second task is then to characterize a variety of potent, low-cost, specific programs to build up these assets among those who need them most–to promote well-being and help protect against physical and mental illness.
A series of research studies from independent researchers have broadly characterized the psychological phenomena that may help identify “health assets”. They essentially conclude, unsurprisingly, that having the resources to be optimistic and have a positive outlook on one’s personal health really makes statistical differences to the probability of experiencing illness and to overall live expectancy. They are useful, despite having this obvious bottom line, in identifying specific “assets” that can be developed through measures ranging from individual counseling to community-wide programs.
An initial prospective study looked at the association between psychological well-being (based on metrics of emotional vitality and optimism) on coronary heart disease in middle-aged men and women. The participants were 7,942 British civil servants (part of the famous Whitehall study—Michael Marmot‘s famous experiment showing the impact of social class on health). Emotional vitality was defined as active engagement with the world (participating in the community), effective emotional regulation (not “going off the deep end” in response to stress) and an overall sense of well-being. Optimism was assessed by participants rating themselves on a scale of 1 to 6 in their response to the statement: “Over the next 5–10 years I expect to have more positive than negative experiences.” Numerous cardiovascular risk factors were measured over five years, including smoking, alcohol consumption, exercise, fruit and vegetable consumption and blood pressure/metabolic factors. Greater emotional vitality and optimism were both significant protective factors against coronary heart disease, independent of metabolic risk factors, gender and age. Similar research among the elderly shows parallel findings for a variety of other diseases.
Another large prospective longitudinal study from 1988-1997 enrolled 4,888 U.S. participants in evaluations of their levels of cardiorespiratory fitness, negative emotion and positive emotion. Subjects were then followed for approximately 15 years. Analysis was adjusted for significant health factors such as age, BMI, physical activity, smoking and alcohol consumption. The study found that men and women with high levels of negative emotion were 1.5 times more likely to die than those with lower levels of negative emotion, but whether individuals had higher or lower levels of positive emotion did not change their mortality rate. Having both a low level of negative emotion and being fit reduced premature death by 63 percent, compared to unfit peers with high levels of negative emotion. There was no difference in these findings between those over 60 years of age versus those younger, nor between healthy and unhealthy people.
The next task was to ask: can such emotional states be encouraged or buffered through medical, social or economic programs?
From theory to practice
It turns out that some countries have already introduced these types of measures during the wake of the 2007 economic recession. For example, in recent research, we found that programs called “active labor market programs” (ALMPs) introduced in some Western European countries to rapidly re-integrate unemployed people into workforce training and even menial jobs that emphasized emotional well-being and self-worth, rather than putting them through bureaucratic and psychologically-debilitating months of unemployment, had dramatic benefits to cardiac and mental health. Statistically speaking, they prevented some countries from experiencing mortality spikes that their neighbors without these programs experienced.
A broader set of strategies to promote community engagement and reduce negative outlooks, coupled with economic support, is now being modeled in Copenhagen. Parallel strategies are also being employed among US combat veterans and men in San Francisco who have suffered from myocardial infarctions and have type-A personalities (yes, that’s a bit self-referential). Whether these interventions are effective–and which set of interventions will be most potent–is still the subject of ongoing study. Information about these measures can be found at the University of Pennsylvania hub on these studies.
The broader implication of these findings for medicine is that our day-to-day clinic visits with patients should also take on a different tone. Already, the field of geriatrics has forced us to refocus our attention from the mere extension of life to the emphasis on suffering and quality of life. Now, these initiatives give us a sense that simply prescribing more pills for mortality benefits among all folks may not be as relevant as focusing on life’s “assets” and the goals of patients in living a satisfying existence. The work of Seligman and others will be relevant to learning just how we might adjust our practice to incorporate real strategies in positive health counseling to enhance health-promoting outlooks and behaviors, just as we now emphasize motivational interviewing and related techniques to counsel against “bad” behaviors like heavy drinking and drug use.