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In Social Determinants, Personal Responsibility, and Health System Outcomes, I discussed the limitations of the potentially attractive (at least to the empowered) concept of “personal responsibility”. In its more malignant form, personal “accountability” as put forward by John Mackey of Whole Foods, there is the implicit – sometimes explicit – suggestion that people might be denied care if they had not personally taken on the behaviors that might have helped prevent the condition. Of course, which behaviors, for which conditions, and how much remains unspecified. Aerobic exercise 60 minutes daily? Or would 30 minutes 3 times a week qualify? No sweets, or cookies only on Sunday? How many? I am reminded (well, I’m old) of former North Carolina senator Jesse Helms who was against funding the treatment of AIDS as it came from inappropriate and immoral behavior (MSM sex and IV drugs were, I think, what he had in mind). Of course, he strongly supported both tobacco and funding the treatment of heart disease (such as he, a heavy smoker, had).
Of course, I’m sure that, today, smoking is on John Mackey’s “no-no” list, but it is the concept of “your bad habits are worse than my bad habits” that is emblematic of the “different from me is bad” phenomenon that ebbs and flows in world history, and has become increasing common both in this country and around the world. The Tea Party movement is one domestic example; at the “Values Conference” recently held in Washington, Christine O’Donnell, the newly-elected Republican candidate for Senate in Delaware, wowed the crowd with the line "We're not trying to take back our country. We ARE our country." Except, of course, for those who are not part of “we”. Me, for example. And those other ‘others’: those who believe in brotherhood, caring, and diversity.
But surely John Mackey is not embracing racism or prejudice? Classism, maybe; certainly discrimination against those who don’t adopt the health behaviors that he endorses. One might ask: why don’t they? And, if one does, we can get a good answer from a wonderful article that appeared in the recent Annals of Family Medicine, “Capability and clinical success”, by RL Ferrer and AV Carrasco (disclosure: Dr. Ferrer has previously been a guest-author on this blog.) Going beyond the “social determinants of health”, which is a relatively passive model in that it mainly just describes them, Drs. Ferrer and Carrasco discuss the concept of “capability” of health behaviors. They draw upon the work of Nobel Prize-winning economist Amartya Sen, who introduced this concept, and that of Jennifer Prah Ruger of Yale, who has developed its use in health (e.g., “Health capability: conceptualization and operationalization” in the January, 2010 issue of the American Journal of Public Health). The concept of “capability” goes beyond simply evaluating people’s behaviors, and looks at opportunity to perform those behaviors, which is not equally available to all:
“What distinguishes the capability framework from other approaches to evaluation is its emphasis on opportunity as well as achievement. Turning raw capacity (e.g., the ability to walk) into action (walking for 60 minutes a day) to achieve a goal (being physically fit) requires that there be real opportunities to do so. Examining the set of potential opportunities that are viable for a given person (a capability set) helps to define what goals are attainable. For instance, a capability set for physical activity would encompass the various modes and durations of physical activity that are realistically achievable given a person’s constraints of time, money, support from others, physical abilities, and what is locally available.”
Capability is influenced by individual, social, psychological and environmental factors, as well as by income. Money – or lack of it – is a major component, but not the only one, because other features can mitigate or exacerbate financial issues. The concept of “social capital” developed by Robert Putnam (“Bowling Alone”[1]) and others is one formulation of this. In his book Heat Wave[2], Eric Klinenberg describes how the deaths in the 1995 Chicago heat wave, while associated with age, illness, poverty and availability of air-conditioning, were also associated with the availability of social supports. He notes the differential death rates in two adjacent low-income communities. In one, the decimation of the commercial sector and fear of crime had people locked in hot apartments, while in the other neighbors checked on the old, sick, and poor, and merchants on the vibrant shopping street allowed them access to their air-conditioned stores. “A capability perspective,” write Ferrer and Carrasco, “implies that poverty should not be defined primarily by income but by scarce opportunity to pursue valued activities and goals. Strong external supports create opportunities that enable people with limited income to pursue their goals for healthy living. Capability is thus a key mediator of the relationship between socioeconomic position and outcomes.”
What Ferrer and Carrasco add to the discussion is the clinical component, discussing how the clinical relationship can take account of capability, and how the clinician can play a role in enhancing the health of patients through understanding and acting to help ameliorate its impact on those who have little. They suggest an example of a series of questions (their Table 2) that a clinician can ask in order to assess an individual’s capability of adopting different healthful behaviors. They also provide suggestions for how the clinician or practice can access help through social service agencies, public health departments, programs of connectors or promotores, and grass-roots agencies. Clinicians may be able to assist in helping people gain access to wholesome food or places to exercise, and to groups that would support their activities.
Of course, in some cases, maybe often, these programs will not already exist. In that case, it could become the role of the clinician or the practice, or even better the health system (or, to use the terms of the new ACA law (PL 111-148), the 'Accountable Care Organization') to help develop such programs in the interest of promoting the health of its patients. Indeed, we should and must if we are interested in promoting health and not just casting blame.
[1] Putnam, Robert D., 2000, Bowling Alone: The Collapse and Revival of American Community, Simon & Schuster, New York, NY
[2] Klinenberg, Eric., 2002, Heat Wave: A Social Autopsy of a Disaster in Chicago, University of Chicago Press, Chicago.
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