Today I wanted to talk about something that I think is really at the core of a lot of the frustration people face with health and healthcare. I want to talk about an issue that touches on entitlement, privilege and how much we take our modern lifestyles for granted. This will be a long post because I really want to get to the core of this issue, so if you're interested in reading please set aside a good ten minutes. So strap in and let me tell you why health is not a human right
TL;DR
Let’s start with a story, one that really highlights the core of our problem, about two different women who have startlingly different outlooks on health. Anne is a fifty-six-year-old woman born in Australia who’s been a teacher her whole life, Sam is a twenty-one year old Pakistani who emigrated to Australia three years ago with her family. Anne is presenting to a private practice (despite having access to free healthcare in Australia) because she doesn’t like the doctor at her local bulk-billed (public) clinic. Sam is presenting because she doesn’t have access to the public system and our clinic has discounts for students. Both women present feeling a bit ill, both with a cough and both have been a little under the weather.
Anne, our fifty-six-year-old, entered the consulting room, sat down opened up with “I need you to give me some antibiotic for this cough”. The doctor took a moment to process this demand before launching into a full history and examination, a rather comprehensive and impressive one too. She made sure that Anne’s cough wasn’t anything suspicious, clearing her clinically for likely pneumonia, cancer or any of the other myriad of potentially dangerous underlying conditions which can cause a cough. After about six minutes Anne was barely containing herself and soon snapped again “I just need the antibiotics, please”. Unfortunately for Anne, she didn’t need antibiotics. A simple viral infection of the upper airway is pretty standard stuff for a GP clinic, and without an indication of an underlying bacterial cause or a risk of progression to one, antibiotics will only make things worse. The doctor explained this to Anne she was treated to a ten-minute lecture on how Anne, a fifty-six-year-old teacher, knew her own body and knew she needed these antibiotics. Because “no matter what the doctors say, I know it always goes away quicker if you just give me the pills”. I won’t take you through the rest of the lecture. But needless to say, it involved accusations that the medical system had failed her, that the doctor had failed her, that the doctor had breached our her duty of care and Hippocratic oath (she hadn’t) and that she’d never met such a rude doctor in her life. Anne left disappointed and without antibiotics.
So let’s meet Sam.
Sam presents almost exactly the same as Anne, except she’s accompanied by a younger brother to help translate for her. Despite the language barrier Sam manages the introductory pleasantries that Anne forgot and launches into her presentation. Exactly the same as Anne, but Sam has a history of Cystic Fibrosis (CF). CF is a congenital condition which (in short) causes the lungs to clog up and become prone to infection. While Sam’s cough is something she’ll live with for her whole life, a fever and fatigue indicate a clear underlying infection which needs to be treated. Sam left happy and with antibiotics.
Despite the differences in these patient’s and the differences in their management there’s on really important thing to point out. Even in Australia, Sam has a life expectancy of 38, years of which she’ll spend plagued with poor lungs. Anne has a life expectancy closer to 84. Statistically Anne will still be alive when Sam dies, and yet she was the one who felt failed by the healthcare system.
But if we break this down, we’ll realize that it’s not really a healthcare system which is at the stem of Anne’s anger. A combination of being frustrated at being sick, a lack of education surrounding antibiotics and a pretty shitty personality, mean Anne is angry at her poor health and simply taking it out on the healthcare system, and those who work in it.
This is the underlying problem when people confuse their right to healthcare healthcare with a right for health. It’s something that I feel is at the core of our obesity and diabetes epidemic, at the heart of our burgeoning healthcare budgets and that underpins the alternative medicine movement (google: “synonyms for cause” :/).
To really understand this concept, we have to understand what a human right is. The UN declaration of Human Rights was first drafted in 1948, and while it’s just one organisations views on what Human Rights are, it’s a good place to start. The declaration includes 30 Individual’s Rights, too many to list here, but let’s have a look at some of the key ones…
All human beings are born free and equal in dignity and rights. - Article 1
Everyone has the right to life, liberty and security of person - Article 3
Everyone has the right to recognition everywhere as a person before the law - Article 6
Everyone has the right to freedom of peaceful assembly and association - Article
While these are just some cherry-picked examples, you get the idea. A right is an expectation that we'll be treated in a particular way by people or society. These are rights that should extend to everyone, in every situation. These are rights that depend on the interactions between people, and thing we can control. What Human Rights are not, are rules that contrive to oppose nature or chance. *”Everyone has the right to live a life free of natural-disasters” is not a human right, because no human on earth is able to control this. It’s down this line of reasoning that we see quite clearly that health cannot be a human right. Humans are as incapable of controlling harm from health issues, as we are of controlling harm from natural disasters. We can optimize health, as we can optimize our buildings in earthquake-prone zones. But when disaster strikes, it will strike regardless. Because health, particularly communicable, degenerative and congenital disease, are so hard to control, freedom from them cannot be designated as a ‘right’. For this reason, it’s not surprising that the only mention of ‘health’ in the UN’s declaration of human rights is in the line…
“ Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”
-Article 25
But this does raise another point… the UN does list ‘medical care’ in their definition of "right to a standard of living adequate for [] health", and importantly so. Medical care, also known as healthcare, is a vital component of our human rights. It’s a component that so many nations are utterly failing billions of people around the world with. And this brings us back to Anne and Sam.
Anne and Sam both had health problems, and Anne and Sam both had access to (excellent) medical care. Sam understood quite well the difference between her right to health and to healthcare, and didn’t pin her underling health problems on the people trying to help her address them. Anne on the other hand was incapable of making this distinction. Anne think’s it’s her right to be healthy, and it’s our responsibility to make her healthy, and if we’re incapable of doing that then we’ve breached her rights.
This is the disconnect that is at the core of Anne’s terrible behaviour and (along with a real shitty personality) is the reason why patient’s like her should not expect to be accepted back into medical centres where they hurl abuse so freely.
But people being incapable of making the distinction between their right to health and their right to healthcare leads to problems that are far more engrained than just verbal abuse. So let’s chat about the heart of one of our global health crises.
Because we can summarise this confusion between a right to healthcare and a right to health as "people feel they’re owed good health by healthcare systems and medical practitioners" we’ll simply call it Health Entitlement. It’s this concept of health entitlement that I think is at the core of three of the most pressing current issues in global health…
Lifestyle-related disease is perhaps the biggest problem in global healthcare at the moment, and it’s a pretty simple monster on the surface. To summarise in one phrase, we can probably just say ”modern lifestyles are not healthy”. In almost all developed and developing nations we’re eating more, eating worse, exercising less and putting ourselves under more stress. This has led to the obesity, diabetes and heart disease epidemics that we’re all so familiar with.
But (almost) everyone knows the dangers of a poor lifestyle, (almost) everyone knows how to live healthy, so why aren’t we doing it? Well, one explanation is health entitlement. People feel that their lifestyle is their responsibility, but the health problems that stem from it are not. When someone becomes hypertensive, has a heart attack or gets arthritis in their knees, they understand this is a symptom of their lifestyle, but they also see the treatment of their new condition as the problem of the health establishment. You’d be amazed at how many patients just look frustrated when you tell them a pill for their sore knee isn’t going to do as much as losing 5kg. This is where the problem lies. Not in people not understanding that poor lifestyle leads to poor health, but that that poor health is their poor health. Their responsibility, their burden and a part of their new lifestyle.
This is not about ascribing blame or finding fault, it’s about creating a paradigm shift in how people view health. Too many people see health only through the lens of disease and refuse to make sacrifices or changes until they’ve reached the point where they’ve deteriorated far enough to need medical attention. We need a paradigm shift in our attitude towards health and this begins with giving people the tools and education to deal with their own health through all its stages, and to understand how health fits in to and interacts with their overall lifestyle.
If we want to see change in people’s approach to taking responsibility for their own health, we need change the rhetoric around health. We need to emphasise health in education, not as once-off lessons or development day, but as a core part of any well-rounded education. Health should be up there with language and math as the basic building blocks of any education from primary school through till high-school graduation.
Let’s take this back to Anne and Sam. Sam had grown up with her disease and from a young age learned to incorporate health into her everyday lifestyle. In part because if she didn’t then she’d soon be very ill. Anne on the other hand has avoided ill health most of her life. With no active education on the subject and no brushes with disease to help enlighten her, Anne enters the healthcare system with an attitude of health entitlement. She understands her illness is not her fault but incorrectly deducts that it is therefore not her responsibility. She has decided that it is a medical professional’s job is to fix her, yet this is not what the medical establishment is for.
The medical establishment is for consolation about health. Doctors and allied health professionals form a network of professionals on which everyone should be able to call, when they need help making a decision about health or disease. Health, lifestyle, disease, medicine, medical investigations, surgery. This is a complex labyrinth the extent of which we can’t expect everyday people to understand. It is a medical professional's job to work with patients to allow the patient to decide on the best course of action for their own health and help them leverage the powers of this system. Now anyone living in the real world now would understand this is not how healthcare works currently. In part because of paternalistic attitudes of some medical practitioners, in part because patient attitudes do not allow it and in part because funding and time constraints actively preclude this. But it’s a model of health, of practitioner-patient interaction and of cooperative decision making that we should be working towards.
It’s no myth that healthcare is expensive, and that this cost is growing exponentially. This is a multi-factorial problem which draws upon increasing reliance on new and expensive technologies, an aging population and bureaucratic + administrative inefficiencies. It’s a problem affecting every nation (even the US, despite a lack of a proper public healthcare system), and it’s a problem with no simple fix.
Somewhere in this cocktail of disaster, however, I’d like to slot in my idea of health entitlement. People who do not understand health, or take responsibility for their health, are a massive financial burden. If people live healthy lifestyles they’re less likely to need medical attention, less likely to develop lifestyle-related diseases (ie: heart disease) and less likely to fail early treatment options. People who take responsibility for their poor health and understand the limitations of modern medicine and of medical practice are less likely to sue hospitals, doctors and other health institutions because of a failure to meet their unrealistic expectations. Perhaps most importantly, those in charge are less likely to hold medical institutions to unrealistic standards, which results in a loss of focus on patient-centered care and an obsession over KPIs.
Finally, a favourite topic of mine, and forgive me if I seem overly critical but I can assure you it’s justified. The parasitic cretins that have conglomerated to form the heaving pile of festering pseudoscientific garbage that is the alternative medicine movement feed off health entitlement. The alternative medicine’s profiteering business model is dependent on people who want quick-fixes for complex problems and aren’t prepared to educate themselves far enough to understand the underlying flaws in what they’re being sold or told. This is why alternative medicine tends to stick to ‘warm-and-fuzzy’ easy to understand terms, like “natural”, “ancient” and “superfood”… I could go on for days (and probably will in future posts) but the long-story-short is that this industry would die if people took responsibility for their own health.
It’s hard to sell a super-food to someone who’s well aware of the pros and cons of their diet. This doesn’t mean we all need to convert to a perfect lifestyle. It’s about making responsible enough to ensure that when we make decisions about our health, we make educated decisions.
I’ll use myself as an example. I live a stressful life as a medical student, with multiple side-projects and extra-curricular responsibilities which eat into any potential time for leisure and relaxation. I understand that this stress will lead to issues with sleep, with poor diet and with a lack of exercise, yet understanding this I still chose to pursue my busy lifestyle. This is my choice and the outcomes of this choice are my responsibility. So if I see a commercial on the internet for a "natural new pill that’ll stimulate me during the day, burning away the fat, and let me sleep like a baby at night”… I’m not going to be interested in the least. I know the changes I need to make are lifestyle related, and I know when I chose to pursue a less stressful lifestyle my sleep diet and physical activity will improve. I also know that if this pill was a legitimate option, it would be one everyone was using. (A huge clue to bullshit medical claims is that there are no ‘secret’ effective health products, if it works well you’re guaranteed it’s known well!)
Ultimately the alternative medicine industry feeds of those who don’t want to be responsible for their own health. It’s for people who feel the established medical system has failed them by being unable to offer easy, painless and side-effect devoid cures for medical issues that have been accumulating due to decades of poor lifestyle choices. But it also preys on people who’re clutching at straws for treatments to incurable cancers, disabilities or degenerative conditions. People who don't fall into this category of health entitlement. FInally, alternative medicine perpetuates a culture of health entitlement because that is the culture that it profits off.
While I think the concept of health entitlement is an important one, I’d also like to say a word on some of its limitations. I must emphasize that this is not an idea that should be utilized to ascribe blame or fault to people for their poor health. It’s not a weapon for morons who want to push their lifestyle choices on others. It’s not a line in the sand which splits those who’re healthy and places them on a moral high ground above those who are not. It cannot be applied to people who, due to a lack of education or a lack of cognitive capacity, are incapable of taking responsibility for their own health.
Avoiding health entitlement comes down to taking responsibility for one’s own health. For understanding the health implications associated with the decisions we make day-to-day, and accepting responsibility for the unfavorable outcomes when they do occur. It’s about working with medical professionals, instead of expecting them to do the work for you. It’s a simple concept, but one that is so important if we want to address sustainable healthcare in the future.
As always, thanks for taking the time to read my post, especially since this was such a huge one! I appreciate any comments or feedback, and if anyone has anything to add or wants to disagree on any point I always encourage discussion below!
Thanks heaps team!
-tfc
References
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