The Biomedical model of health is perhaps the oldest of health paradigms, where freedom from disease, pain or defect is the core focus. The physician typically inspects the patient ‘after’ the onset of an ailment and studies the pathology of disease, physiological mechanisms at play, as well as the biochemical processes. Under the biomedical model, the emphasis is on ‘cure’ and ‘healing’ through scientific application of medical principles as and when a medical condition presents itself. While this goal is perfectly legitimate, the critics of the Biomedical model point out its narrow focus, which largely leaves aside the social, economic and psychological factors that often precede and determine the health of an individual. (Wyman, 2000, p.77) It is due to this lack of wholeness in the conventional biomedical model of health, that scholars and thinkers have devised other wholesome perspectives of health. They have added newer dimensions to the study of human health, and the result is the invention of alternative perspectives such as the Biopsychosocial model of health (loosely referred to as the social model). The dominant discourse of the social determinants of health paradigm
“assumes a socio-environmental approach to health primarily “concerned with risk conditions rather than risk factors”. These conditions include poverty; income, gender, racial, and sexual inequality; stressful environments; housing and living conditions; education and early child care; food security; employment and working conditions; social inclusion and exclusion; and globalization. Efforts to attend to health inequities by anyone working under this paradigm would, therefore, address some or all of these issues.” (Ashcroft, 2010, p.251)
The Biopsychosocial paradigm was first expressed by physician George Engel in 1977, where he asserted that human beings are “dynamic systems whose functioning depends on the holistic integration of biological, psychological, and social factors; indeed, according to the biopsychosocial model, these factors are fundamentally interrelated and interdependent.” (Garland & Owen, 2009, p.191) What Engel was critiquing was the reductionism of the then dominant biomedical model, “which assumed that molecular biological processes (for example, genes, biochemistry) immutably dictated physiology and behaviour, a simpleminded biological determinism nonetheless took root, becoming widely and uncritically accepted.” (Garland & Owen, 2009, p.191) At the time of Engel’s introduction of this new model, he was met with much scepticism. But recent evidence and empirical data validate his theory.
The Biomedical model is as old as the history of modern medicine, where the emphasis is laid on scientific and rational understanding of pathology. This included a thorough approach to comprehending the biological mechanisms down to their molecular level. While this model largely holds forte within the confines of the clinic, it proves inadequate in explaining or addressing why some individuals/communities are more prone to certain illnesses than others. In other words, vast strides were made under the Biomedical model, in terms of advances in technology and the standards of medical professions. Yet, there was also the accompanying thought that people’s health conditions do not purely depend on advances in science and the medical professions but are also greatly influenced by social factors of well-being. And this is where, one begins to see chinks in model’s armour. A classic case in point is the spread of tuberculosis. As statistics on this feared epidemic shows,
“the biomedical knowledge of this disease and of its cure, the penicillin vaccine, is a crucial but in itself insufficient factor to successfully fight the epidemic: more important have been and continue to be the battle against social inequalities and the improvement in living conditions and educational levels of the poorest sections of the population. Above all, public health, and society’s commitment to a TB-free environment as a ‘public good’, more than biomedical science, have been and still are crucial factors in the eradication of this epidemic. As the TB example shows, the degree of social well-being of individuals, social groups and populations influences both their health needs and the effectiveness of health professional performance, both in terms of demand and supply.” (Leonardis, 2006, p.19)
The litmus test for the efficiency and effectiveness of any public health system (as well as for the health model it espouses) is its performance in a crisis situation. Civil societies have come to expect basic protections at the time of these crises. Such emergencies also test a government’s/ true ability to act under pressure. In other words, “they define a state’s capacity to protect its population while exposing its vulnerabilities to political upheaval in the aftermath of poorly managed crises” (Gorin, 2002). In the context of economic globalization at the turn of the new millennium, more than ever before, the general public demand transparency and accountability in global public health systems during medical and natural disasters. To gauge the robustness of conventional health models in this new globalization paradigm, we need to study recent cases of acute public health emergencies. The Indian Ocean tsunami of 2004 and Hurricane Katrina are particularly relevant to this analysis. In the cases of Hurricane Katrina and the Indian Ocean tsunami, the advantage of a globally coordinated public health arrangement comes to light. It also goes on to show that tackling (if not preventing) such crises in the future should begin through structural and systemic re-adjustments to public health systems. What these two examples prove is that the scope of the biomedical model (as it exists today) is too narrow to satisfactorily address natural disasters and other public health emergencies. (Brocato & Wagner, 2003, p.118)
Another area where the weaknesses of the biomedical model are exposed is in dispensing care and treatment for mental illnesses. A mental illness is a disorder that causes mild to severe abnormalities in thinking, cognitive functions and behaviour patterns of the affected people. If these disturbances are too severe, they may impair a person’s ability to cope with life’s ordinary demands and routines. Mental illnesses are still stigmatized in contemporary society, in spite of a general increase in awareness about such diseases as depression and anxiety. Even the very term ‘mental illness’ has a negative connotation to it as opposed to ‘physical illnesses’. The widespread perception is that mental illnesses are somehow ‘worse’ and patients afflicted with it “unpredictable” and “dangerous”. While such labels are applicable to a small fraction of patients, a majority of them are ‘normal’ individuals by common standards. Their disorders and disturbances only affect their concentration, cognition and efficiency. Yet, they get ostracized for their condition. It is not an even keel with all types of afflictions. Some of them like schizophrenia are subject to more ridicule and stigma than say depression. (Naidoo & Wills, 2005, p.221)
Where the biomedical model has let down society is in interpreting mental illnesses as largely due to ‘imbalances’ in certain chemicals in the brain. For example, depression is believed to be due to an inadequate supply of serotonin, norepinephrine and dopamine in certain cerebral regions. This view fails to adequately account for the psychological factors that lead to a state of depression. Some of the anti-depressant and anti-psychotic medicines currently in use (more popular ones include Zoloft, Prozac, Lexapro, etc) have not been studied for their long-term usage. Consequently, reports of detrimental effects of these drugs and their intolerance in the long run are emerging slowly. Not only is the biomedical model of psychiatric treatment contested in its therapeutic approach, but it is also intertwined with the interests of the powerful pharmaceutical industry. As it functions today, the health care industry is designed to ensure sustained profitability of pharmaceutical companies, insurance companies, private hospitals, etc. This condition should alter radically and the emphasis should be laid on meeting the health-care needs of patients. In other words, an ethical healthcare system, informed by the biopsychosocial model, should put people’s healthcare needs above corporate profits. (Graham, 2000, p.44)
Social determinants of health such as geographical location, gender, age, ethnic origin, education level, governance and socioeconomic status are all factors that determine a nation’s healthcare system. Even as contemporary society enjoys technology aided interconnectivity, hundreds of thousands of people are still living under hostile health conditions. While the rich among us are getting richer, a significant percentage of our compatriots are still confronting poverty, hunger, illiteracy and threat of infectious disease on a day to day basis. Such a situation betrays the socio-political realities of our communities, with its attendant failure to invest in public health projects. On the one hand the cultural, economic and social conditions of social groups and populations influence their health needs. This correlation has been identified and widely documented by numerous studies, especially in the case of health conditions in developing countries. (Eisenberg, et.al., 2007, p.1216) The health conditions of a population are, in this regard, an inseparable facet of the general state of well-being. Some fundamental indicators of health, such as morbidity rates, mortality rates and life-expectancy at birth show a strong link not only with
“indicators related to aggregate socioeconomic conditions (income, employment, nutrition, etc.) but also with indicators related to other indirect variables of well-being. For instance, education, especially women’s education, rates have a significant impact on human development indicators, such as the life expectancy at birth rates. (1) Equally significant is the correlation between political variables–such as the presence of democratic institutions, the degree of participation in public life–and the population’s conditions of well-being, of which, as we mentioned above, health is an important component. (2) Together, the inequalities between countries and within a country, i.e., the imbalances, discrimination and exclusion from access to economic, social, cultural and political resources, are a crucial factor in explaining the unequal exposure to diseases on the part of individuals, social groups and populations.” (Leonardis, 2006, p.19)
As an acknowledgement of the injustices, inequalities and disadvantages inherent in the dominant biomedical model, a consensus is emerging within the international community toward the formation of a more equitable public health system. Such conceptions as the international development targets, which were discussed in recent WHO meetings try to deal with diseases of poverty head on. Simultaneously, there has been a growing concern from private corporations to involve themselves in civil society organizations. The global health initiative is a product of these developments. If implemented properly, we may see a more equitable global health system in the not-distant future. But for this dream to be fulfilled, private corporations and government health agencies need to put in concerted and coordinated efforts based on shared values. In these times of radical change to economic organization of the world, the need to build bridges between medicine and public health and between ethics and human rights become all the more important. (Lietz, 2006)
Even in the public health system in the United Kingdom, the influence of the biopsychosocial model is becoming evident. The National Health Service (NHS), which is a government run public health care enterprise, is an important institution in Britain. Both the Tory party and the New Labour Party have competed to claim the NHS as their own and no election campaign in Britain is without numerous references to the benefits offered by the NHS. While some of the claims made by politicians might be overstated and exaggerated, it is indeed true that the NHS is an indispensible and integral part of the lives of British citizens. Several public opinion polls also show that people living in the UK are generally happy and appreciative of the services offered by the NHS. There are good reasons why this is so. For example, the NHS provides free healthcare service to all citizens at point of delivery, and made available on the basis of need and not on the ability to pay. In the years before its creation, nearly half the general population could not avail of basic healthcare. Back then, access to basic healthcare was a matter of social class and the ability to pay. But all that changed for good with the unveiling of NHS in the year 1948. The success, sustainability and the goodwill generated by the NHS is a strong proof for the veracity of the biopsychosocial model of health. This success is made possible by the fact that the NHS stands for protecting the greater common good as opposed to profits of private interests.
With increasing progress in the medical sciences, and especially psychology and sociology, our society is at an opportune time to turnaround the dark history of stigmatization associated with mental illnesses. And the tools offered by biopsychosocial model of health can come handy in achieving this goal. Yet, while physicians try to understand the workings of the brain, many of its functions still remain a mystery. Even at the most advanced research laboratories, the abnormal functioning of the brain is only understood at a theoretical level, without any concrete evidence to substantiate it. But what is important though is that there is a consensus within the medical community that most psychiatric illnesses are induced to physiological (or organic) causes. To this extent, they are on par with physical illnesses like cancer and tuberculosis. Hence, the sufferers should be treated just like the physically afflicted get treated. This thesis is one of the most important one to have emerged in medical sciences over the last decade or so. It is hoped that a wider awareness of this new sociological understanding of mental illnesses will pave the way for a more tolerant society. (Naidoo & Wills, 2005, p.203)
Finally, one of the key syntheses of the points made above is implementation of recommendations given by the World Health Organization. Drawing inspiration from the merits of the biopsychosocial model, the report by WHO Commission on the Social Determinants of Health (CSDH) suggests a comprehensive array of changes to give all societies world class health care. These recommendations could have the widest impact on patients, families, and communities, including treatment of people with substance abuse and more aggressive management of obesity. There is strong proof that shows that carrying out these proposals to the word will bring the healthcare industry’s performance on par with advances in medical technology as well as lifting the ethical standards prevailing in the health system. The CSDH
“combined epidemiological analysis of health inequalities within and across countries with an essentially cosmopolitan ethical argument for motivating global social action to mitigate ill health and health inequalities. The CSDH’s report is the first to apply social epidemiological analysis to global health, which is distinct from the prevailing analyses of the causes of ill health, which focus on such individual-level determinants as exposures to harmful agents, behaviors, and genetics, or those analyses that overlook social-group differences in health outcomes within countries. Moreover, the commission’s justification for addressing ill health and health inequalities within and across countries is grounded in the ethics of justice, as opposed to such reasons as national security or interest, economic growth, charity, or a self-evident “contain and control” epidemiological imperative. The moral principle that informs the commission’s work is that where one can do something to alleviate avoidable suffering through reasonable means, one should do so.” (Venkatapuram, 2010, p.119)
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