Sandro Galea. Well: What We Need to Talk About When We Talk About Health. New York: Oxford University Press, 2019. 274pp, $28.95.
One of my favorite ways to orient new medical students on the clinical team is to riff on a 2015 study by the County Health Review: only 16% of overall patient outcomes (defined as quality and length of life) are attributable to what we do in medicine. It’s a sobering statistic — one I use to encourage the students (and myself) to “hold our 16%” with humility.
Physician and professor of public health Sandro Galea is even more modest: a mere 6% percent of our collective health is determined by access to medical care. Galea wrote Well: What We Need to Talk About When We Talk About Health to nudge public discussion of health away from the 6–16% we typically associate with medical interventions and toward a meditative, “long view of health.” His approach is sweeping: twenty chapters on subjects like money, power, politics, place, compassion, hate, luck, justice, death. He brings in climate change, gun violence, celebrity influence, industrial practice, education, urban design, road safety, fast food.
Well covers a lot of ground, reading as a series of brief, tight reflections on what most medical workers will recognize as “the social determinants of health.” And while I share Galea’s formation as a primary care physician and sympathize with his vision, I see three challenges to changing what we talk about when we talk about health:
It is difficult to talk about health when we don’t agree on what health is.
As Galea argues, “all members of the human family wish to be healthier.” But this begs the question of what we mean by “health.” The World Health Organization (WHO) famously defined health as “not merely the absence of disease” but “the complete physical, mental and social well-being” of the human person as a whole — a definition so comprehensive in scope as to be unachievable in practice. Leon Kass’s construal of “well-working” is often named in counterpoint to this — narrowing health to “an activity of the living body in accordance with its specific excellences,” in part to give the medical sciences something to aim for. That said, Kass’s definition seems to overlook the relational, entangled aspects of health in which, as Wendell Berry famously put it, “to speak of the health of an isolated individual is a contradiction in terms.”,
Why does it matter how we define good health if we can all agree we want to be healthier? Because contemporary biopolitics favor broad, WHO-ish construals of health in order to justify those individual choices and legally available medical interventions that are not clearly health-restoring — neither in the sense of bodily well-working Kass describes, nor in the richness of Berry’s vision of creaturely enmeshment. Does “good health” include access to elective abortion? To physician-assisted suicide? Can good health include puberty-blocking agents aimed at approximating the bodily experience of the opposite sex? Does the elimination of Down Syndrome make the human family “healthier”? If “nothing is possible without health,” how are we to understand how those with chronic illness can and do live according to what Karl Barth called “the will to be healthy” — a kind of well-working present even within the sick (sometimes especially within the sick)?
Well doesn’t engage these questions. And while all members of the human family probably do wish to be healthier, it depends what we mean by “health” (and certainly what we mean by “all members”).
Medicine instrumentalizes what we talk about.
There is a crucial difference between your physician recognizing you as a whole person and your physician breaking that wholeness down into discrete parts to be categorized, diagnosed, and treated. Obviously, some of this is good. If my son gets pneumonia, I certainly hope his pediatrician uses accurate diagnostics and therapeutics to focus on one aspect of his health. But under the biopsychosocialspiritual model, the clinician can feasibly analyze every aspect of one’s health (literally ana-lysis, “to break down”) and slowly bring each component into ever more totalizing management and efficient reimbursement. I found myself imagining the chapters of Well contorted into yet another checklist or template in the electronic medical record.
And besides, fewer young clinicians want to practice whole-person care to begin with. Medical trainees are increasingly avoiding primary care practices traditionally oriented toward hard-won, long-suffering relationships. Take my specialty of family medicine, which recently had its lowest MD match rate in history. Medical trainees don’t want the hidden life of the preventative physician with a long view of health. They want the tightly controlled and delineated encounters of subspecialty consultation.
Galea is clear that Well is not necessarily directed to medical works. Even so, I worry Well overlooks the extent to which medicine is prone to grabbing jurisdiction wherever it can while simultaneously pushing clinicians into forms of medicine that are largely disinterested in the very vision it is trying to cultivate.
Talk is easy, love is hard.
Wendell Berry writes in “Health is Membership” (necessary reading on this subject, it seems to me) that “people seriously interested in health will finally have to question our society’s long-standing goals of convenience and effortlessness.” As Galea points out, we’ve already shown that we will not tolerate limits even on something as silly as the size of containers used to sell sugary drinks. The last few years of COVID theater, masking, and vaccine controversy are low-hanging fruit here.
My sense is most people understand that their individual health is bound to the health of their neighbors in some way, but they don’t know what to do about it. The kind of collective vision of health in Well is dependent upon the ways of a certain kind of community practiced in living with the sight and slowness necessary to notice one’s neighbor “half dead” on the side of the road (let alone take them in). Galea looks to Augustine, hinting that we ultimately need stories of agapeic love that are “fervent to correct.”
Galea’s use of Dickens’ A Christmas Carol is instructive here. Galea argues that Scrooge’s famous transformation came in a moment of “enlightened self-interest.” He came to see that his health was intimately bound to the health of others — especially Tiny Tim — and changed as a result.
But Galea says more: this is not the only reason Scrooge changes (and surely not the main reason). A better reading is that of a cold and avaricious man who is given the grace of a three-spirited encounter at the threshold of his own grave and in the sight of a suffering child. Scrooge takes up contrition, confession, and conversion — not the baptized selfishness of egoistic altruism: “Hear me! I am not the man I was…”
As the church continues to wrestle with recovering her work and witness in the United States — a country that spends more on medicine than anyone else with worse outcomes than everyone else — I wonder if we might take a cue from the church of the first few centuries. One of the earliest descriptors of Christianity was a “religion for the sick.”
Talk is easy. Absent caritas — what Galea names “a desire for love” — and the traditioned communities that make that love coherent and possible, we will not be able to achieve health, let alone change what we need to talk about when we talk about it. We’ll be left with folks like me, desperately holding our 16%.
- Carlyn Hood, Keith Gennuso, Geoffrey Swain, Bridget Caitlin, “County Health Rankings: Relationships Between Determinant Factors and Health Outcomes,” American Journal of Preventative Medicine 50, no. 2 (2015): 129–35. Cited by the Human Harvard Network Initiative, https://www.humannetworkinitiative.com. ↑
- Galea, Well, 149. ↑
- Ibid., 205. ↑
- “About Social Determinants of Health (SDOH),” March 10, 2021. Center for Disease Control and Prevention. https://www.cdc.gov/socialdeterminants/about.html. ↑
- Galea, Well, xii. ↑
- Ibid., 183–4. See also “Constitution,” 2022. World Health Organization. https://www.who.int/about/governance/constitution. ↑
- Leon Kass, “The End of Medicine and the Pursuit of Health” in Toward a More Natural Science: Biology and Human Affairs (New York: The Free Press, 1985): 157–86, 174. ↑
- Wendell Berry, “Health is Membership,” in Another Turn of the Crank (Washington, D.C.: Counterpoint,1996), 86–109, cited in M. Therese Lysaught, Joseph J. Kotva, Jr, Stephen E. Lammers, Allen Verhey, eds, On Moral Medicine: Theological Perspectives in Medical Ethics, 3rd ed. (Grand Rapids, MI: Wm B. Eerdmans, 2012), 419–25. ↑
- There are other definitions: health as species normativity, integrated “meta-capability,” adaptive potential, value states. See Adam Omelianchuck, “Do You Have a ‘Syndrome’ If You Have a Flat-Shaped Head? Journal of Medicine and Philosophy 43 (2018): 369–80. See Christopher Boorse, “Health as a Theoretical Concept,” Philosophy of Science 44 (1977): 542–73. ↑
- Galea, Well, 33; See also Karl Barth, “The Will to Be Healthy,” in On Moral Medicine, 320–5. ↑
- Joshua Briscoe, “Shouldn’t We Care for the Whole Person?” Notes From a Family Meeting, May 15, 2022. https://familymeetingnotes.substack.com/p/shouldnt-we-care-for-the-whole-person?s=w. See also Jeffrey Bishop, The Anticipatory Corpse: Medicine, Power, and the Care of the Dying (Notre Dame, IN: University of Notre Dame Press, 2011), 246-253. ↑
- Farr Curlin, “What Does Any of This Have to Do With Being a Physician? Kierkegaardian Irony and the Practice of Medicine,” Christian Bioethics 22, no. 1 (2016): 62–79, 63. See also Phil Whitaker, “Knowing patients well can be life-saving. But family GPs like me fear our days are numbered,” The New Statesman, December 8, 2021. https://www.newstatesman.com/long-reads/2021/12/knowing-patients-well-can-be-life-saving-but-family-gps-like-me-fear-our-days-are-numbered. ↑
- Kenny Lin, “How did Family Medicine fare in this year’s National Resident Match?” American Family Physician Community Blog, April 18, 2022. https://afpjournal.blogspot.com/2022/04/how-did-family-medicine-fare-in-this.html ↑
- Berry, “Health…” ↑
- Galea, Well, 131. ↑
- Ibid., 74–5. ↑
- Ibid., 163. ↑
- Charles Dickens, “A Christmas Carol” in The Book of Christmas (Reader’s Digest Association, 1973): 151–95, 190. ↑
- Roosa Tikkanen, Melinda Abrams, “U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes?” The Commonwealth Fund. January 30, 2020. https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019. ↑
- Gary Ferngren, Medicine & Health Care in Early Christianity (Baltimore, MD: Johns Hopkins University Press, 2009). ↑
- “Sandro Galea: What is the difference between health and medicine?” Instant Genius Podcast. April 2020. ↑
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