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ITEM 2 MODELS OF HEALTH AND HEALTH CARE

Item 2 Models of health


and health care
Roger Ottewill and Ann Wall

The positive and negative models of


health
The underlying purpose of both the positive and negative models of
health is to provide a way of assessing what has come to be called
‘health status’: they both embrace criteria for establishing a person’s
state of health. Each offers a distinctive view of what is meant by
good health and, by implication, ill-health. Without an acceptable
definition of good health, it is impossible to specify and measure
the outcomes of health care services.

The positive model of health


One of the best known of the positive definitions of health is that The positive model of
of the World Health Organization. In defining health as ‘a state of health, as defined by the
World Health
complete physical, mental and social well-being’, the World Health
Organization, is ‘a state
Organization has sought to broaden our view of the nature of of complete physical,
health status and therefore the responsibilities of those who mental and social
contribute in different ways to health care. well-being’.

Those who favour such a definition do so on the grounds that it:


. avoids the crude equation of health with the absence of disease
. recognizes the various aspects of health (physical, mental and
emotional)
. draws attention to the fact that health affects every sphere of
life (work, rest and play)
. incorporates a subjective element – how we feel about our state
of health.
Although the World Health Organization’s positive definition of
health has been extremely influential, it is not without its
limitations. Some commentators have criticized it for being:
. too idealistic, in the sense that it conceptualizes good health in
such a way that it is unattainable – no one would ever describe
himself or herself as being in ‘a state of complete physical,
mental and social well-being’
. all-embracing and undifferentiated, since it seems to imply that
every positive aspect of life is an element of good health
. too generalized, with too little account being taken of the
differences between individuals.
In short, the World Health Organization has not so much defined
‘health’ as simply stated it in terms of another elusive concept,
‘well-being’.

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In response to these criticisms, some of those who subscribe to the


positive model have sought to find more precise definitions. They
have conceptualized health in terms of the capacity to meet the
demands placed upon us, to pursue our aspirations, and to realize
our potential. Whitbeck (1981), for example, defines health as ‘the
capacity to act or respond appropriately in a wide variety of
situations’. By ‘appropriately’, she means in ‘a way that is supportive
of, or at least minimally destructive to [an individual’s] goals,
projects [and] aspirations’.
One of the principal implications of such a definition is that,
paradoxically, good health can coexist with disease or disability, as in
the case of a person with diabetes who is none the less able to fulfil
his or her career potential. Similarly, a woman with no arms who is
able to mother her children appropriately demonstrates the
coexistence of health, defined in a positive way, with disability.
Another implication is that it is often necessary, in assessing health
status, to go well beyond the clinical or medical sphere. There are
many cases where doctors and other health care professionals can
find nothing wrong, but the people concerned are unable to meet
their responsibilities in full, as employees, parents or spouses,
because they are unwell.

The negative model of health


The negative model of In contrast to these positive definitions of health, the negative
health is based on the model is based on the premise that health is the polar opposite of
premise that health is the
disease. On the basis of this model, people are deemed to be healthy
polar opposite of disease.
if no trace of disease can be found, regardless of how they feel or
behave. Conversely, if disease is detected, they are considered to be
unhealthy to varying degrees, regardless of whether or not they
regard themselves as unhealthy.
Thus, unlike positive definitions of health, negative definitions allow
no room for subjectivity. They are essentially objective in the sense
that the presence or absence of disease is established by scientific
investigation. With the advance of technology for the purposes of
screening and diagnosis, the detection of disease – and therefore
the assessment of health status from the point of view of the
negative model – becomes more sophisticated and relies less and
less on patient reporting. For example, conditions such as breast
lumps, kidney stones and arthritis can be detected prior to the
patient having any awareness that something is wrong.
In an ideal world, both models would play an equal part in the
assessment of health status. Inevitably, however, one will normally
take precedence over the other. Which model predominates will be
determined by a number of factors, including:
. the distribution of power between the various stakeholders,
with academics and some health care practitioners favouring
positive definitions and doctors favouring negative definitions
. the stage of development of a health care system, with less
developed, simpler systems tending towards positive definitions
and more developed, complex systems tending towards negative
definitions

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. the particular circumstances of an individual case, with positive


definitions more likely to prevail in community settings and
negative definitions more likely to prevail in hospital settings.
It is important for managers to be sensitive to these factors and to
ensure that full account is taken of the insights which these models
provide in allocating resources and planning activities. By now it
should be clear that good health is a complex phenomenon and its
definition is by no means self-evident. Moreover, the complexity is
compounded when one asks the question: ‘What determines good
health?’.

The biomedical and social models of


health
Inherent in the biomedical and social models of health are differing
views about the principal determinants of health and, conversely,
the principal causes of ill-health. For most of this century the
relatively narrow biomedical model has been in the ascendancy.
However, increasing recognition is now being given to the
contribution which the much broader social model can make to our
understanding of health.

The biomedical model of health


There is a close affinity between the biomedical model and the The biomedical model
negative model of health. Those who subscribe to the biomedical places particular emphasis
on the biological causes
model place particular emphasis on the biological causes and
and manifestations of
manifestations of disease and ill-health. Their basic premise is that disease and
the human body is a machine made up of a number of divisible and ill-health.
abstractable parts. As such, any malfunction (such as disease) is an
‘engineering’ problem which is capable of being tackled by technical
means.
The model has its origins in germ theory, which is particularly
associated with the pioneering work of Pasteur and Koch in the
nineteenth century. This, in turn, gave rise to the doctrine of specific
aetiology: for every disease there is a single and observable cause
that can be isolated.
The principal strength of the biomedical model is that there is a
considerable amount of evidence to support its basic assumptions, in
that specific causes for particular diseases have been found. For
example, exposure to the tubercle bacillus causes tuberculosis,
vitamin D deficiency leads to rickets, a genetic defect causes sickle
cell anaemia, and a hormone (insulin) deficiency causes diabetes.
Against this, however, must be set a number of weaknesses. Critics
of what is seen as an over-reliance on biomedicine draw attention
to the fact that specific causes are a necessary rather than a
sufficient condition for the manifestation of a disease. Not everyone
exposed to a causative agent will succumb to the disease. Some
people even survived the Black Death! More prosaically, during an
influenza epidemic some escape. A further criticism is that, for many
diseases, particularly those where the incidence is currently

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increasing, such as heart disease and cancer, the cause has proved
difficult to ascertain and there appear to be many different
causative agents rather than a single one.

The social model of health


In the social model, the The social model can be seen, in part, as a reaction to the limitations
health of individuals and of the biomedical model. This model is closely linked with positive
communities is seen as
definitions of health. In the social model the health of individuals
the result of complex and
interacting social, and communities is seen as the result of complex and intereacting
economic, environmental social, economic, environmental and personal factors. A definition of
and personal factors health which links the positive and social models is that of
Seedhouse (1988):
A person’s optimum state of health is equivalent to the state of the
set of conditions which fulfil or enable a person to work to fulfil his
or her realistic chosen and biological potentials. Some of these
conditions are of the highest importance for all people. Others are
variable dependent upon individual abilities and circumstances.

Among what he refers to as the ‘central conditions’ for health,


Seedhouse lists not only food, shelter and warmth but also factors
such as access to relevant information and the ability to assimilate
and utilize such information. Thus, for those who adhere to the
social model, the determinants of health are far more varied and
broader in scope than those found in the biomedical model.
Because of the range of its determinants, the potential for allocating
responsibility for ill-health is much greater. In the case of biomedicine it
has been easier to regard ill-health as an ‘act of God’ and therefore
nobody’s fault. By contrast, the social model gives rise to many
possibilities for apportioning blame and has resulted, on the one hand,
in ‘victim blaming’ and, on the other, in pointing the finger at
deficiencies in public policy and the behaviour of business and industry.
With respect to ‘victim blaming’ there are those who argue that ill-
health is primarily, or even exclusively, due to individual actions
(such as smoking) or inaction (failure to wear a crash helmet for
example). In their view, far more responsibility should be placed on
the shoulders of individuals for adopting lifestyles which will
minimize the risks of becoming ill.
Those who draw attention to the part played by government and
business take the view that responsibility for behaviour and health
should not be laid solely at the door of the individual. People are
influenced and constrained by the social, economic and physical
environment in which they live and the organizational setting
within which they work. Thus the failure of governments to provide
adequate housing may result in individual behaviour which is
damaging to health and can also lead directly to an increase in
respiratory disease. Similarly, in seeking to maximize profits some
businesses will market goods and services which are known to be
damaging to health.
In short, the social model sees health primarily as an issue for – and
the responsibility of – society as a whole. Among other things, this
means a collective responsibility for ensuring that individuals have
every opportunity to adopt healthy lifestyles.

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The preventive and curative models


of health care
By now it should be clear that the positive and social models of
health are more likely to lead to an approach to health care in
which top priority is given to prevention. Likewise, application of
the principles of the negative and biomedical models will result in a
curative approach. The point is frequently made that the Health
Service has always been a curative or ‘treating’ service because of
the dominance within our health care system of the stakeholders, in
particular doctors, who espouse the negative and biomedical
models. At the same time there have been constant calls for more
resources and attention to be devoted to prevention.

The preventive model of health care


Advocates of the preventive model: The preventive model
stresses the importance of
. give pride of place to measures designed to reduce the incidence taking action to reduce
(the number of new cases) and prevalence (the total number of the incidence and
cases) of ill-health – for example, promotional campaigns, prevalence of ill-health.
ensuring that people have access to the prerequisites for health
(adequate housing, satisfactory diet, etc.), screening, and
vaccination and immunization
. argue for what has come to be called ‘healthy public policy’
which means, in effect, making ‘healthy choices the easier
choices’ – for example, ensuring that healthy food is cheaper
than unhealthy, and creating environments in which it is difficult
to smoke
. focus on the health care needs of groups (such as ethnic
minorities) and/ or the population at large
. emphasize the importance of mobilizing a wide range of
agencies such as academic institutions, voluntary organizations
and local authorities, and tapping as many different sources of
expertise as possible, both professional and lay
. see community settings, such as the home, schools and leisure
centres, as the most significant locations for the provision of
health care
. stress the need for more epidemiological research, to enhance
our understanding of the links between disease patterns and
social factors in health and health care.
The major strength of a preventive approach is that, for most of us,
‘prevention is better than cure’. This is the case at the level of the
individual, who thereby avoids the experience of ill-health, and
society at large, which is saved the expense of treatment and the
use of human resources to which ill-health invariably gives rise.
There are a number of drawbacks, however. First, preventive
strategies are more difficult to justify because of the long-term
nature of the outcomes and uncertainty regarding their effectiveness.
For example, the effect of anti-smoking campaigns in primary schools
will not be felt for several years, during which time many other
factors will play a part in influencing people’s smoking behaviour.

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Second, the collaboration necessary when several professional groups


and agencies are involved in planning and implementing a preventive
programme is extremely difficult to sustain in practice and can easily
lead to a dilution of responsibility. Last, prevention often raises
people’s expectations to such an extent that some will inevitably be
disappointed. This is the case with people who, despite their healthy
lifestyle, succumb to heart disease.

The curative model of health care


The curative model Those who subscribe to the curative model take as their starting
concentrates on taking point the insights provided by the biomedical model and
action to cure disease.
concentrate on measures designed to cure disease. They:
. give pride of place to what are called, in the colourful language
sometimes used in this context, ‘magic bullets’ (wonder drugs,
heroic surgery, and other techniques)
. focus on the treatment of individuals
. legitimize the central and dominant role played by clinicians
(i.e. professional healers) in the health care process
. regard hospitals as the principal delivery point for health care
services
. place particular emphasis on research into the biological causes
of ill-health and methods for tackling the malfunctions referred
to earlier.
The overwhelming argument in favour of this approach is that many
diseases and conditions can be successfully treated through the
application of science and technology, for example, hip
replacements and pain reduction through the application of drug
regimes. Moreover, in so doing, it has made a significant
contribution to improving the health status and well-being of many
people.
None the less, it is not without its drawbacks. For many conditions,
particularly those which are currently major causes of morbidity,
such as lung cancer, cures have remained elusive. In addition,
treatment is often very costly in financial terms and carries with it
risks, which Illich (1975) has called ‘iatrogenesis’ – illness caused by
the action of doctors, such as addiction to and the side-effects of
drugs. At the same time, the curative approach has made only a
limited contribution to improving the health status of the population
as a whole. This is reflected, in part, in the increasing demand for
health services. Likewise, it has made very little impact on the
endemic inequalities in health status associated with class, gender
and ethnic origin.
These weaknesses have received increasing attention in recent years
and this has caused the hegemony of the curative approach to be
called into question. Consequently, prevention is being accorded a
higher profile. It is, however, important not to lose sight of the
value of the curative approach and not to over-emphasize its
weaknesses. Managers have a central role in striking a balance
between prevention and cure and in exploiting the creative tension
between them.

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References
Illich, I. (1975) Medical Nemesis: The Expropriation of Health, Calder and
Boyars.
Seedhouse, D. (1988) Ethics: The Heart of Health Care, John Wiley.
Whitbeck, C. (1981) ‘A theory of health’ in A. L. Caplan, H. Engelhart and
J. J. McCarthy (eds) Concepts of Health and Disease: Interdisciplinary
Perspectives, pp. 611–626, Addison-Wesley.

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