Perspectives on Science and Christian Faith

The Coming Revolution in Health Care

JAMES F. JEKEL
Department of Epidemiology and Public Health
Yale Medical School
New Haven, Connecticut 06510

From: JASA 30 (September 1998): 116-123.

[Presented at the 32nd Annual Meeting of the American Scientific Affiliation, Nyack College, Nyack, New York, Aug. 14, 1977]
We are in the midst of a revolution in the assumptions, goals, and methods of health care. Assumptions seriously being questioned include: (1) that scientific medicine is largely responsible for our current level of health, (2) that scientific medicine will markedly extend our life expectancy beyond current levels, (3) that the biomedical model is a satisfactory guide to medical practice and research, (4) and that most health care is provided by professionals. There is increasing concern that the current approach to health care is causing physical, social, and cultural harm and that the current directions cannot continue for cost reasons alone.
The Scriptures inform our current dilemma by emphasizing (1) that health is the result of a way of life and not a product that can be purchased from healers, (2) that we must be as concerned with improving the quality of life as with extending its length, and (3) that health care is best when provided in the context of the family and immediate community.

In 1902 Thomas Kuhn published his now famous book, The Structure of Scientific Revolutions, in which he debated the logical positivist idea that science progresses gradually from one stage to the next strictly on the basis of reason.¹ Kuhn argued that science progresses from one stage to another through intellectually and emotionally turbulent periods of conceptual revolution, and these revolutions arc followed by extended eras of relative quiet, during which the scientific field seeks to reexamine its subject matter from the new perspectives and assumptions acquired during the revolution,. Kuhn called the new synthesis a "paradigm." One quiet period continues until the assumptions and methods of the reigning paradigm prove insufficient to answer the new questions that appear. Thus, according to Kuhn, the progress of a science is more like climbing uneven stairs than riding up a smooth ramp.

It is my thesis that we are now entering a period of conceptual revolution in the area of health care
which bears similarity to those described by Kuhn. The assumptions and methods of current medical research and care are increasingly being subjected to intense debate, which will lead to a different synthesis or "paradigm," probably within the next decade. However, the current biomedical paradigm's assumptions and methods are deeply entrenched at every level of our society, and the forces fighting for this paradigm are extremely powerful in terms of scientific, economic, and political influence. Moreover, the health care system is now the nation's largest employer, with representatives in almost every community in the country, which means that there is a large constituency available to fight for the status quo.

The Past and Present Contributions of Medicine

The current medical paradigm is not as sharply delineated as, for example, were the geocentric view of the universe or Newtonian physics. Nevertheless, many of its assumptions may be summarized. First, it assumes that our current level of health is due mainly to our public health/medical care system, which began with the discovery of the germ theory in the late 1800's. It is a popular idea (even among medical professionals) that the control of communicable disease is largely the achievement of medical science (through immunization, antibiotics, etc.) However, historians have increasingly come to understand that medicine as it has been practiced during the past century has had little impact in producing the level of health we enjoy today. The sanitary revolution in Europe, particularly in England, was well under way, and its impact in reducing infant mortality, was already being seen before the development of the germ theory. The sanitary revolution came about from the personal convictions of many people, which were partly biblical in origin, that it was better for society's health and morals to live its cleanliness rather than in filth. The germ theory reinforced that movement, of course, and strengthened its theoretical foundations, but it was not its cause. Yet it was the sanitary revolution which, as much as any other thing, has restored society to today's levels of health. The term "restored" is probably correct here, because many of the infectious diseases, including the leading killers, tuberculosis and infant diarrhea, were made the severe problems they became by the processes of urbanization and industrialization. Their resolution over the past century has been primarily a process of learning to live in industrial cities without opening the floodgate to disease.

Tuberculosis, for example, was the leading killer in the industrial West in the mid-1800's, with death rates that sometimes exceeded 500/100,000 per year. The death rates of tuberculosis have been declining steadily since about 1850, and by 1949 it had become only a shadow of its former self. However, medicine had no effective cure (none that could significantly affect the death rate) before 1949, when streptomycin was discovered. Tuberculosis had declined, not because of scientific medicine, but because of a number of related social and technical changes that were largely outside the purview of medicine: improvement in society's (1) nutrition, (2) socioeconomic status, and (3) living and working conditions (especially the reduction of crowding), and (4) the elimination of the spread of tuberculosis through milk by Pasteurization and by the elimination of infected herds, and (5) increased genetic resistance of the population to the disease. Most of the epidemic infectious diseases were also declining rapidly during the late 1800's and early 1900's, before medicine had either immunization (except for smallpox) or antibiotics. Today, few evaluative studies of the effectiveness of modern medicine show striking results, and most of the current screening programs are considered to be of dubious value. The world-renowned bacteriologist from the Rockefeller Foundation, Rene Dubos, has put it this way:

Clearly, modern medical science has helped to clean up the mess created by urban and industrial civilization. However, by the time laboratory medicine came effectively into the picture the fob had been carried far toward completion by the humanitarians and social reformers of the nineteenth century. Their romantic doctrine that nature is holy and healthful was scientifically naive but proved highly effective in dealing with the most important health problems of their age. When the tide is receding from the beach it is easy to have the illusion that one can empty the ocean by removing water with a pail. The tide of infections and nutritional diseases was rapidly receding when the laboratory scientist moved into action at the end of the past century.²

Medicine as it has been practiced during the past century has had little impact in producing the level of health we enjoy today.

The past President of the Blue Cross Association, Walter J. McNerncy, listed as the first health myth to he debunked the idea that "Must health services make a big difference in the health of a population, thus, with enough money, health can be purchased."³ Even an apologist for modern biomedical technology, Dr. Lewis Thomas, put it his way:

In any case, we do not really owe much of today's population problems to the technology of medicine.
Modern medical science is a recent arrival, and the world population had already been set on what seems to he its irreversible course by the civilizing technologies of agriculture, engineering, and sanitation,-most especially the latter.⁴

Life Expectancy

A second incorrect assumption of many persons is the promise of medical science for the future. Since our life expectancy at birth has increased approximately 30 years over the past century, it is assumed that biomedical technology will continue this progress into the future, so that in another century or so, our life expectancy may he 100 or so. This overlooks the fact that during the same past century, the life expectancy of white males at retirement age (65) has increased but 2 to 3 years! Life expectancy at birth has improved greatly due to the reduction of infant mortality, childhood diseases, tuberculosis, etc.; what it means is that most infants can now expect to reach retirement age. What has not happened is a major change in the maxilength of life, since modern medical science has little capacity to alter significantly the course of the chronic degenerative diseases, Indeed, it is as true now as when Moses wrote the 90th Psalm (approximately 1400 years B.C.) that ". . . the days of our years are threescore years and ten; and if by reason of strength they be fourscore ..."⁵ Again, as Dr. Thomas says:

If we are not struck down prematurely by one or another of today's diseases, we 1ive a certain length of time and then we die, and i doubt that medicine will ever gain a capacity to do anything much to modify this. I can see no reason for trying and no hope of success anyway. At a certain age, it is in our nature to wear out, to come unhinged and to die, and that is that.⁵

He does add a very salutary emphasis on the quality, rather than the quantity, of life, which is certainly consistent with the biblical perspective:

My point here is that I very much doubt that the age at which this happens will be very drastically changed, for most of us, when we have learned more about how to control disease. The main difference will be that many of us will die in relatively good health . . . .⁷

The Bible, as well as the more astute of medical scientists, cautions us not to look to scientific medicine to bring us eternal life.

The Biomedical Model

Another problematic assumption of modern medicine and health care is what many have called the "biomedical model." This model assumes that our lack of health is primarily due to disease, that most of our diseases produce anatomic and physiologic changes, and that diseases can be cured if these alterations are restored to their normal state.⁸ Disease is seen fundamentally as alterations in body biochemistry, usually in predictable patterns. The task of the scientist and physician are to identify the abnormalities associated with the disease and discover methods of restoring these to "normal", which is seen as being equivalent to a "cure."

The largest institution built in honor of this assumption is the National Institutes of Health, which was started in 1948 and which has guided the direction of American medical research and (hence) medical education and practice since the early 195O's. There have been great achievements in some dimensions of our knowledge of disease, but great problems have also been produced. Medicine has rapidly become more complex and dependent upon expensive diagnostic and therapeutic technology. This has, in turn, forced specialization and other expensive changes. Legal and ethical problems are created faster than they are solved. The human dimension is being lost from the medical care process.⁹) Medical education has almost lost sight of the increasingly well documented fact that the origins of most of our diseases lie predominantly in our nutrition, our environment, and our behavior. As Engel has put it:

in modern Western society biomedicine not only has provided a basis for the scientific study of disease, it has also become our own culturally specific perspective about disease, that is, our folk model (italics mine). Indeed, the biochemical model is now the dominant folk model of disease in the Western World.¹⁰

Engel suggests the new paradigm should be based on a "biopsychosocial model", in which the role of social and psychological factors is adequately emphasized. I would like to add the spiritual dimension to his list, for I believe that we will sooner or later discover that we cannot adequately deal with the subject of health without considering the issue of the meaning and purpose of life, and man's relationship to his Creator. One modern area of interest where this is gradually being appreciated is the field of thanatology.

One of the glaring weaknesses of the biomedical model is its lack of understanding of, or ability to deal with, health. There are more than one hundred schools of disease in this country, but, to my knowledge, not one school of health. Medical schools notoriously focus most of their effort on teaching about disease, including
its diagnosis and treatment. Schools of public health emphasize the origin of disease and the organization of care, rather than how to promote health. But, as the World Health Organization's preamble states: "Health is . . . not merely the absence of disease or infirmity." We must face realistically the fact that we do not have
a "health care system . We have a "disease care system," and very little that its does is done to promote health in a positive sense.

The Definition of Health

One of the difficulties we have in setting national health goals and measuring our progress (or lack of it) is our inability to define health. The WHO statement just quoted defines health as ". . . a state of complete physical, mental, and social well being . . .", which, in addition to being unattainable in this life, is not very helpful. Duhos has clearly pointed to one weakness of the biomedical model:

health and disease cannot be defined merely in terms of anatomical, physiological, or mental attributes. Their real measure is the ability of the individual to function in a manner acceptable to himself and to the group of which he is a part.¹¹

Thus, social functioning, not biochemical state, may be closer to a useful concept of health, and it also may be easier to measure. It is not as widely accepted to date, partly because it also has ambiguities and partly because to agree on such a definition would be to open the flood gates to a reallocation of resources away from what are now considered health activities. Dubos and others have also emphasized that health is not so much freedom from stress (which is unattainable in our sinful world) as it is the ability to adapt to the stresses to which we are subject:

the states of health or disease are the expressions of the success or failure experienced by the organism in its efforts to respond adaptively to environmental challenges.¹²

Rates of death and illness are clearly insufficient to measure health; at most they measure some of the deviations from it. In the last analysis, one must agree with Duncan Clark that: "As for health no fully acceptable concept exists".¹³ Here is certainly a fruitful field of research for those with a biblical perspective.

Iatrogenesis

In my first contact with our Professor of Surgery, Carl Mover, he began the lecture with the Latin phrase: 
primun nocere, which, I understand, can he translated: "first, do no harm." It is a principle that made sense at that time (1958) and makes even more sense today. The first obligation of a physician should be not to harm the patient. If that is so, it would seem reasonable that the first obligation of the health care .sysie;st also should he to do no harm. Yet there is evidence that the medical care system does a great deal of harm to individuals through unnecessary surgery, inappropriate or unnecessary medications, and pointing to pharmacologic or surgical solutions whea changes in environment, life style, or human relationships are the only remedies that offer hope for real improvement. Much of the unnecessary surgery that is done comes from economic pressures in cities where we have more surgeons than are needed, and it is reinforced by the population's tendency to look to surgeons as modern miracle workers. Overmedication may arise from a sense of despair on the physician's part ("I don't know what else to do") or from the need to get on to the next patient (one study showed that physicians often write prescriptions for medication as a ritualistic way of terminating a patient visit, even in the absence of a clear indication for the medication.)

Less studied, but perhaps more important sources of harm from our medical care approach are the social and cultural effects of a strongly institutionalized biomedical model of health and healing. Illich calls these "social and cultural iatrogenesis," and these consist in the social and cultural distortions that occur by strict adherence to the biomedical model of disease¹⁴ Zola also points to the social dangers inherent in the increasing medicalixation of life.¹⁵ We are turning less to religion or law for the final decision to social problems and more to medicine. Therefore, behavior (e.g., murder) which centuries ago might have been dealt with as a problem of sin, and more recently as lawlessness, is now first subjected to a medical test: if the perpetrator was somehow "ill" at the time of the act, he becomes "not guilty by reason of insanity." The point here is not to argue whether this is good or had, but to emphasize that the final tribunal and the first agent of attempted change, in this, as in countless other areas of life, is coming to he medical authority.

The medicalization of life also increases the social control which a small group of persons (health "professionals") exercise over others. Thus we have, as a society, given to the physician the ultimate right to decide who does and does not have the right to large amounts of society's resources. A decision to give someone a heart transplant, or to put someone on renal dialysis, may cost society $50,000 or more. The decision to give one person these resources means that others will not have access to them, because our resources as a society are limited, Second, society has given the physician the power to give to some, and to exclude from others, the right to a socially acceptable form of deviance known as sickness. Taleott Parsons first clearly defined the social contract of Western Society known as the "sick role," in which the society gives certain benefits to the person who is defined by a "competent professional" to he ill, and in turn requires certain behavior from that person. Society offers: (1) lack of blame for his/her condition and (2) to excuse him/her from normal role obligations during this period, in return for which society requires the individual (1) to want to recover and to seek out competent medical help and (2) to cooperate with those who are prescribing the therapy. Sociologists are increasingly concerned over the power given to the medical profession.

Costs

It is the costs of our current direction in medical care, however, which will ultimately force major changes in the way we approach health care. The society will no longer tolerate an inflation in the cost of medical care that is twice the national average when we

What has not happened is a major change in the maximum length of life, since modern medical science has little capacity to alter significantly the course of the chronic degenerative diseases.

are already spending about 9% of the gross national product on medical care. We hear stories such as that General Motors now pays more to Blue Cross and Blue Shield than to U.S. Steel in a given year. That might be all right if we were getting a proportional benefit, but increasingly the population is becoming restless and is questioning whether it is receiving its money's worth. Certainly, the marvels continue for many forms of acute medical problem and accident. But as the population now is mostly living past retirement age, a higher and higher proportion of all care is for chronic problems, where the biomedical approach has the least effect. Dr. Thomas admits that the application of inadequate technology is costly:

Offhand, I cannot think of any important human disease for which medicine possesses the capacity to prevent or cure outright where the cost of the technology is itself a major problem. The price is never as high as the cost of managing the same diseases during the earlier stages of ineffective technology.¹⁶

He admits that "halfway technology" is inordinately costly, and the central question is whether biomedical technology will ever he able to become cost-effective technology in the chronic degenerative diseases, or will we become saddled with increasingly costly (but ineffective) halfway technology that also compounds ethical and legal questions? For example, will biomedical technology ever be able to restore a smashed braincaused by highway carelessness? Or a cirrhotic liver, almost destroyed by alcoholism and malnutrition? Or an emphysematous lung that has been destroyed by decades of smoking and infection? Most, if not all, of the examples of "effective technology" relate either to infectious disease or to acute medical and surgical emergencies. We should not deny the individual contributions of modern medicine in these areas; indeed we should be grateful. What concerns me is that modern medicine, which can be so effective in restoring individuals with certain kinds of problems to productive life, is now becoming so saddled with ineffective technology in other areas that its real contributions are becoming less available to the average peson. It is even less likely that our expensive western medical technology, complete with its folk model of disease, can benefit the developing nations, even though we are exporting it at this time.

A new approach to health and health care is clearly needed. What insights do the Scriptures provide as to what changes should he made in our assumptions, concepts, and approaches?

Prevention as the Way to Health

There are many biblical insights which could be brought to a consideration of health; foremost among them is that health is the result of a way of life and not the product of nostrums. The broad commands of Scripture portray Cod's will for His people: 'Ye shall he holy, for I the Lord your Cod am holy." (Lev. 19:2). The holy walk with Cod emphasized not defiling oneself (Lev. 11:44); this required, among other things, that man distinguish "between holy and unholy, and between unclean and clean." (Lev. 10:10) The Scriptures provided the guidelines for the Israelites to keep a holy walk with Cod, and obedience had the promise of physical blessings (health) as well as spiritual blessings:

If you will diligently hearken to the voice of the Lord your God, and will do that which is right in his sight, and will listen to his commandments, and keep all his statutes, I will not pot any of the diseases upon you which I brought upon the Egyptians, for I am the Lord who heals you. (Ex. 15:26)

At the pool of Bethesda, Jesus healed the man who had been ill for 38 years and told him "Sin no more so that nothing worse befall you." In Leviticus 18:5, Cod tells His people through Moses, "Therefore keep my statutes and judgments, which, if a man does, he shall live by means of them." Other Scriptures could be quoted, but the main point is that the biblical view of health is something that was a result of one's entire way of life, not a commodity that could he purchased from healers. Health was something that included the idea of wholeness, soundness, safety, and peace. Our world desperately needs to get away from the idea of health as a commodity, a product, and see it as an organic part of one's way of life.

The specific elements that are most clearly related to good health can be identified by means of epidemiology, the science of determining why disease (or health) occur when they do and in whom they do. Fundamental to good health is nutrition,

Nutrition. Malnutrition can be either undernutrition or overnutrition. By and large, undernutrition is the plight of the poor wherever they are in the world, and overnutrition is the companion of the well-to-do. Undernutrition not only robs one of the vigor to be creative and productive; protein undernutrstion, in particular, also combines synergistically with the infectious diseases to produce high mortality rates among children, particularly following the period of weaning. Measles is a serious but seldom fatal illness among unimmunized but well nourished children, but it has case-fatality rates as high as 20 to 25% among malnourished children, a death rate hundreds of times as high as among well nourished children."¹⁷ On the other hand, overnutrition, particularly when combined with a sedentary life style, contributes to a variety of degenerative disorders in adults, such as coronary artery disease, strokes, and diabetes. For example, the dietary intake of refined sugar (sucrose) in this country in 1850 was about 40 pounds per person per year; now it is over 100 pounds per person per year.

The Environment. A second foundation of health is a clean environment. This includes cleanliness from the many microbes capable of causing severe disease in man (although it does not imply a sterile existence.) The importance of this was demonstrated during the sanitary revolution. It includes clean water, food, and living environment. More recently we have become more aware of the problem of toxic substances in water, food, and the air, but at present we have only hints as to how this pollution may affect human health.

Behavior. Central to a way of life is one's behavior. Every aspect of our behavior has health implications, although we often do not realize this. Most Americans who smoke are aware of the potential risks that smoking brings for cancer of the bronchus, throat, nose, and mouth. Less well known is that cigarette smoking also increases the risk for heart attacks. Still less well known to those involved is that the Islamic custom of "purdah", by reducing the amount of sunlight acting on ergosterol in the skin (and hence reducing the available vitamin 0) leads to osteomalacia in adolescent women. This, in turn, frequently produces deformed pelvises and difficult labor and delivery causing infant and maternal mortality.

In many of the developing nations, women seek to wean the children early and convert to bottle feeding, in order to imitate the wealthy. Because of the lack of refrigeration, the milk is likely to be swarming with bacteria, and due to the low purchasing power of many who do this, the "milk" may be only water colored with a small amount of powdered milk.¹⁷ It is not known how much malnutrition among young children is due to early weaning from the breast to the bottle, but the toll is undoubtedly heavy. Moreover, by shortening the nursing period, women reach peak fecundity sooner following the delivery of a child than they would if they nursed over a longer time, and thus this behavior pattern also contributes to increased worldwide fertility.¹⁸

One of the commonest types of infectious disease in the West are the venereal diseases. Estimates of the number of new cases of gonorrhea last year go over two million. Syphilis, although not rampant, remains steady at approximately 100,000 per year in the United States. A newly appreciated venereal threat is from herpes viruses, especially HVH II. Antiobiotics have proved impotent to eradicate these diseases; control of behavior could!

The above three factors, nutrition, environment, and behavior, are the primary factors influencing the level of health any population enjoys. Medical care is at most the "fine tuning" of our health level; it is these factors that determine the "channel." It is instructive to review the biblical concern for human nutrition, sanitation, and behavior. The concern for proper and pure food is seen in many biblical references (Table I). The concern for personal cleanliness, for pure water, for sewage disposal, for rapid burial of the dead, and for isolation from contamination by discharges, are quite specific. Behavior was carefully prescribed both as to justice and as to cleanliness, and venereal disease was effectively prevented by the code of sexual morality (Ex. 20:14, Lev. 18:20, etc.). Moreover, the priest served as the health officer, to oversee that the community was holy and clean, to diagnose and treat problems, and to pronounce healed persons clean.¹⁹

In summary, the biblical insight that health derives from a holy and clean way of life, and not from purchasing the services of healers, is a perspective that must he recovered by our society if we are to achieve the measure of health we desire at a price we can afford. But who can influence human behavior? Suffice it to say that how we behave derives from what we ultimately believe is of greatest value, and it is here, in determining the priorities of individuals, families, and communities, that religion has its most crucial impact on health.

Quantity or Quality of Life?

It is only in recent years that any serious challenge has been raised to the priorities of medical care; heretofore the first priority has been to save (or prolong) life, regardless of the cost in money and suffering. Death rates are the best developed and most used measure of the success or failure of our medical care system. The development of the technology of medicine to include organ transplants, artificial life support systems, etc. has forced reconsideration of the limits of medicine with respect to prolonging life. For a while there was a lot of talk of "cryogenics", in which it was the hope to freeze bodies immediately upon the point of death and keep the body in deep freeze, along with all of the medical records, until medical science discovered a way to thaw the body and revive it and simultaneously, cure that disease.

Increasingly there is an appreciation for the fact that saving lives is an appropriate first priority in acute

One of the glaring weaknesses of the biomedical model is its lack of understanding of, or ability to deal with, health.

disease, but that improving the quality of life is a more appropriate and realistic goal than extreme efforts to prolong life when it comes to the chronic, degenerative diseases. Even a leading proponent of biomedical technology seems to be saying the same thing.²⁰ The problem is that although there is increasing lip service paid to the idea of retooling the delivery of care to emphasize the quality of life, these priorities are seldom reflected in the objectives of current medical research and education. Just as nutrition is a neglected subject in our schools of medicine and public health so is the subject of rehabilitation; "cure" is taught much better than "care". But for economic reasons, among others, new kinds of primary care professionals are being trained (e.g., nurse-practitioners and physicians' assistants) who often have a better grasp of the meaning of "care" than do many physicians. The cost of hospital care is forcing the expansion of home care programs. People are finding that alternatives such as Hospice are better for persons dying of cancer than the typical acute hospital.'° The coming revolution in medical care will move the "quality of life" to a new place

Table I
Representative Selections from the Old Testament Sanitary Code
Key texts: Leviticus 19:2; 10:10
1. Personal Cleanliness
a. Hand washing, esp. before meals-Mark 7:1-3 b. Whole body after contamination-Lev. 15:5 c. Wash clothes after contamination-Lev. 11:28; 15:5
2. Pure Water Supply
a. Avoid water contaminated by dead animal-Lev. 11:32-36
3. Sewage Disposal
a. Bury it outside the camp-Deut. 23:12-14
4. Bury Dead Soon
a. Before nightfall-Deut. 21:23; Acts 5:6
5. Pure Foods
a. Fruits & vegetables not prohibited b. Meats-Lev. 11:1-8; 29-31 c. Fish-Lev. 11:9-12 d. Don't eat dead animals-Deut. 14:21 e. Don't eat old food-Lev. 19:5-8
6. Isolation
a. If one touches the dead-Lev. 5:2; 22:4 b. If one touches unclean discharges-Lev. 5:3 c. For those who have a discharge-Lev. 15:1-13 d. For those who have skin diseases-Lev. 13 e. Of a woman following childbirtb-Lev. 12:1-8 (prevents epidemic "childbed fever") f. Terminal disinfection-Lev. 15:1-13; 14:34-48
7. Control of Venereal Disease
a. Morality-Ex. 20:14; Lev. 18:20
8. Priest is the Health Officer
Leviticus 13, 14

Nutrition, environment and behavior are the primary factors influencing the level of health any population enjoys. Medical care is at most the "fine tuning" of our health level.

of prominence in the priorities of medical care.

The biblical message is concerned for both the quantity and quality of human life, but these are not primary goals. Bather they are the result of obedience to God as revealed in the Scriptures. The biblical concern for faith, obedience, holiness, and justice clearly place those who stand in the Hebrew-Christian tradition in the position of supporting a balance between the two, and we should vigorously support efforts to restore concern for the quality of life to its rightful position in medical care. Moreover, as one considers the nature of "health", it is important to see that the healthy person is one for whom life, and all of its activities, has deep personal meaning. At the level of tactics, Viktor Frankel has demonstrated how important it is for life to have meaning.²¹ He gives one example of how an elderly man was restored to mental health when he saw that his widowhood and its resultant loneliness meant that his beloved wife did not have to suffer the same; his suffering then had meaning for him and became a last sacrifice for her. Only then was it tolerable, because it bad meaning. Going further, it yet remains for someone to demonstrate that human wholeness, health if you will, must include our ability to stand before God as justified sinners; there are suggestions that those who wholeheartedly embrace the full theological meaning of the Bible are better able to live, and to die, in health. The area needs far more demonstration as well as research.

Care Must be in the Context of the Family

Doe of the current myths about medical care is that most medical care is given by health professionals. Levin and others have emphasized that, in fact, perhaps 75% of all health care in this country is given by individuals to themselves or to members of their families.²² It is just as foolish to see this as bad as it is to consider all professional care good. There is currently a powerful movement, often called the "self-care" movement, to increase the competence of nonprofessionals to care for themselves and others. This is not to imply that "kitchen surgery" will return, but rather that all efforts should be made to give the individual person and family as much responsibility over their own lives and health as possible. This implies that the role of the physician will increasingly become (1) to do the highly technical advanced diagnosis and treatment, and (2) to serve as consultants-yes, consultants-to those giving most of the health care: families and non-physician primary care persons. We cannot afford to restore physicians to their past prominent role as givers of primary care; they are too costly, and they are not trained well for that task, anyway.

Norman Cousins gave a dazzling account of his determination to treat himself for a condition considered medically hopeless, and of his success.²³ The prominent sociologist Lois Pratt points out that "the more numerous and vital the functions the family performs successfully for its members, the stronger is the family system; the fewer the important functions performed, the weaker the system."²⁴ From this she goes on to conclude:

The family is a social unit with considerable potential for performing health care, since families are held legally responsible for sustaining their members' health, they maintain a physical plant which is suitable for health care practice, and the members live together in relationships of mutual care and support.²⁴

In contrast to the potential of the family to perform health care, she reminds us of the current trends, and in this she is absolutely correct:

The emerging medical care system is based on specialization of work, centralization of activity in large complex units, hureancraticizatinn of the work unit, control by management over work and personnel, corporate involvemeat in and exploitation of all aspects of the health market, and extension of profit-making to all sectors of health care.²⁴

One of the byproducts of these large health institutions we are creating is a tendency to impersonality of care.22 How can costs he reduced and care he as personal as possible? By restoring it to the context of a loving family. The medical care system should he, in the last analysis, a family support system, or so it seems to me. However, at the present, families do a better job of supporting the health system (most persons in health care are doing well economically) than the system is doing of supporting the family (office and clinic hours are for the convenience of the provider rather than the patient, as are appointments, etc.)! The emergency room has gained immense popularity not because it is the best place to receive care, but because it is the only place people know will be open 24 hours per day with someone there to see them.

Whether self-care as a movement will be sustained, its existence has shown that there arc options available to the family. Whether the family will play an increased role in the future in "selecting, coordinating, and supervising professional care; determining the forms and conditions of medical intervention; evaluating the outcomes of all these interventions; maintaining health records on the family; and planning a healthy lifestyle, including the choice of community residency, employment, leisure activity, diet, and other health maintenance practices"²⁴ remains to he seen. Certainly not all families or individuals now either want this role or are capable of it. But in this direction may lie our best hope for both economy and effectiveness of health care.

The Bible does not appear, at first glance, to inject itself into this debate, but on further consideration it would seem to suggest that healing is, in fact, the proper role for the family, including the larger family composed by a religious congregation. The Fifth Commandment (Honor thy father and thy mother) is often interpreted only in terms of young children and their parents. However, Jesus interpreted it in terms of caring for ones aged parents (Mark 7:10-13). If interpreted also, or primarily, in this way, the promise (long life) has special meaning. In Acts 6 and James 1 there are evidences that the early church received and acted upon the command to care for each other, and James 5:14 shows that this includes a healing ministry. The oil in this passage should probably be seen as giving a medication that was conceived as having medicinal value, rather than primarily spiritual significance (for example, note the use of oil in Luke 10:34). The pattern of individuals giving health care to each other in a family context would appear to have solid scriptural support.

Haggerty is one of many whose studies have shown that persons under stress have a higher risk of disease. He suggests that clinicians may become more effective in preventing the harmful potentials of stress by involving supportive institutions beyond the primary family: the extended family, peer groups, religious groups. The assumption behind such a proposal is that man is a social creature who needs complex and supportive interaction with groups. Without it, he gets sick, just as an infant deprived of love tends to die.²⁶

I would like to conclude with two quotations from Canon Max Warren's book entitled The Christian Imperative:²⁷

The fundamental sicknesses of men have always been sicknesses of the spirit and the mind. Never, perhaps,
was this more obviously so than today . Only a healing which makes a man whole and integrates him with his fellows in a true community, living in a right relationship with God and with the good earth which God has given man, only such a healing is adequate to the imperative 'go heal.' For this reason the Church must not imagine that it can relegate the responsibilities of its healing mission to a representative company of physicians and nurses, surgeons and anesthetists, pathologists and dispensers.

The . . . hospital must he seen as an integral part of a common task in which Church and school and farm are seen, not as the possibly attractive agencies for the employment of those with no skill in healing, but as the actual points at which most of the healing is done, the front line of the attack an human need. To these, the real centers of healing, the hospital will be related as a source of inspiration, a school of technical knowledge, a resort for such eases as demand specialized skill, but not as being itself the center of healing.

REFERENCES

¹Wade, N. "Thomas S. Kuhn: Revolutionary Theorist .of Science." Science 197, 143-145, July 8, 1977.
²Dubns, Rene. Mirage of Health. New York: Doubleday and Company Inc., 1961, pp. 30-31.
³McNerney, Walter J. "Health Care Reforms-The Myths and Realities." Am. I. Public Health 61, 222-232, February 1971.
⁴Thomas, Lewis. "Aspects of Biomedical Science Policy." An Occasional Paper of the Institute of Medicine, National Academy of Sciences, 1972, p. 10.
5Psalm 90:10 (AV)
⁶Thoinas, op. cit., p. 9.
⁷Ibid.
⁸Engel, George L. "The Need for a New Medical Model: A Challenge for Biomedicine." Science 196, 129-136, April 8, 1977.
⁹Duff, R. and Hollingshead, A. B. Sickness and Society, New York: Harper and Row, 1968.
¹⁰Engel, op. cit.
^1lDubus, op. cit., p. 214.
¹²Duhos, Rene. Man Adapting. New Haven: Yale U. Press, 1965, p. svii.
^l3Clark, D. W., in Preventive Medicine. Clark, D. W. and MacMahon, B., editors. New York: Little Brown and Company, 1967, p. 3.
¹⁴Ilhch, Ivan. Medical Nemesis. New York: Random House, 1976.
¹⁵Zola, I, K, "Medicine as an Institution of Social Control" in Cox, C. and Mead, A., Eds. A Sociology of Medical Practice. London: Collier-MacMillan, 1975.
¹⁶I'homas, L. op. cit., p. 11.
¹⁷Scrimshaw, Nevin. "Ecologic Factors Determining Nutritional State and Food Use." In Alternatives for Balancing World Food Production Needs. Ames, Iowa: Iowa State University Press, 1967, pp. 35-50.
¹⁸Rosa, Franz W. "The Interaction of Breast Feeding and Family Planning in the Americas." (mimeographed).
¹⁹ See Leviticus, chapters 13 and 14.
²⁰Craven, J. and Wald, F. "Hospice Care for Dying Patients." Am. J. Nurs., Oct. 1975.
^2lFrankel, V. Man's Search for Meaning. New York: Washington Square Press, 1959.
²²Levin, L.; Katz, A. H.; and Hulst, Eds. Self Care: Lay Initiatives in Health. New York: Prodist, 1976.
²³Cousins, Norman. "Anatomy of an Illness (As Perceived by the Patient.)" New England J, Med. 295, 1458-1463, Dec. 23, 1976.
¹⁴Pratt, Lois. "Changes in Health Care Ideology in Relation to Self-Care by Families," Paper presented at the Annual Meeting of the American Public Health Assoc., Miami Beach, Oct. 19, 1976.
²⁵Dnff, R. and Hollingshead, A., op. cit.
²⁶llaggcrty, B. as reported in Behavior Today 7(42), 2, Nov. 1, 1976.
²⁷Warren, Max. The Christian Imperative. New York: Charles Scribner's Sons, 1955, pp. 8182.