Building bridges - seeing the wood and the trees
Those making public health policies need to be very conscious of the individual ‘trees’ that make up the forest, and those of us directly involved in patient care need to not only look at the ‘whole person’ - body, mind and spirit - but also at the environment in which they live. In the analogy of the paper we need to look out of the windows on both sides of the train. The environment, both physical and cultural within which people live, has a direct effect not just on their bodies but also upon their minds and spiritual aspects. We need to keep one eye focused on the whole person and the other on ‘the forest’ in which they live in order to devise appropriate treatment, explanation and ongoing health advice.
By extension I believe that our responsibility to those individual patients does not stop just by taking environmental factors into account in their treatment - where we see recurrent factors causing ill-health we need to do what we can to change the environment in which they live. Sometimes direct action may be needed, as illustrated by this episode when tutors from PRIME were teaching a programme for primary care doctors in the desert areas of Tunisia. One of the doctors told how he had been encountering many people suffering from diarrhoea. He knew this was because of the poor water supply in that area, and though he had requested better water be installed nothing had been done. “I thought maybe I had more responsibility than just to write a letter,” he said. He requested three days leave, and went sat to the capital in the entrance to the appropriate ministry until he managed to directly approach the Minister. “Within two weeks they started work on the water supply. Now there is less diarrhoea, and my workload is so much less!”
Maybe if we think somebody ought to do something about a problem, maybe that somebody might be me…
The spiritual and cultural environment can play a significant role not only in the cause of illness but also in the attitudes to treatment. Whilst it is very easy to see the link between poor water supply and physical illness, or polluted air and bronchitis, a toxic spiritual environment can also have a detrimental effect on our patients. This could manifest as a dogmatic religious environment, where law and dogma takes precedent over compassion and integrity or an irreligious secular one where individual faith is not allowed to be expressed. Political ideologies can also polarise societies causing division instead of feelings of common interest and community. These can affect our patients. In some societies these influences can be very noticeable, but for the majority the influences are more subtle. Hence an understanding of how these influences work is important if we wish to see positive change.
It is my experience that the individual, especially those working in health, can have a considerable effect if we build bridges with those who lead in both these fields. Thus it is important to form relationships with religious leaders and local or national politicians. When working in Bhutan, I possibly did more to contribute to the well-being of the population through the health education talks we ran than through the tablets we gave out. Noticing some unhelpful thinking about how some diseases were associated with engrained attitudes, I made a point of befriending the local Buddhist abbot and sharing with him the idea that his monks, when they visited distant villages to conduct funerals or other rites, should use the same flashcards that paramedical workers used for health education. He was very happy with this idea, and it made a big difference to the health in some villages. Similarly we are working within PRIME to help Christian pastors understand mental health issues and bringing together faith in modern medical science. By building bridges we can make a difference.
It is possible to make relationships with politicians without it absorbing huge amounts of time. In Bhutan, the local Dzongda (Governor) and I developed a friendship to the extent that he brought together all the National Assembly representatives and village headmen for two days of education to learn about the causes of common diseases. One immediate effect was that on returning to their areas they took actions resulting far less illness. In developing mutual understanding influence can be exerted further up until it reaches national level - such as the campaign to ban smoking in bars and restaurants in the UK. But to do this we need to engage rather than just shout from the sidelines. We need to build bridges of understanding if we want to see changes in the things that shape the environment – physical, cultural and spiritual – that so greatly affects the health of our patients.
1. Shalala DE. The Future of America and Health. National Congress of the Medicine/Public Health Initiative; 3 March 1996; Chicago, Il.
2. Laurie N and Freemont A JAMA. 2009 Jul 1; 302(1): 84–86.
Building Bridges between Health Care and Public Health: A Critical Piece of the Health Reform Infrastructure
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3747986/
