If one considers that access to "sick care" in America is unequal, surely access to health promotion and wellness strategies are just as disparate. The attainment of a good standard of health promotion for the entire population is a reasonable goal. Access to health promotion should not be dependent on socioeconomic status,1 cultural background2 or bias against certain conditions such as learning disabilities, mental health problems and AIDS.3
It's All About Access
What constitutes a society conducive to health promotion and wellness? It can be argued that the promotion of health and well-being often is distinct from the health care system, yet it is intrinsically tied to the health care industry. Health-promotion reform must consider the heavy influence of corporate lobbyists representing the medical-industrial complex that includes the insurance industry, pharmaceutical companies and for-profit hospitals. So where does the chiropractic profession fit into this equation? As practitioners who place an emphasis on natural healing and minimal invasive screening and treatment, chiropractors can and should lead the way in the promotion of health and wellness as it relates to reform of the health care system.
Chiropractic physicians are autonomous practitioners who function at the interface between the consumer and the health care system.4 Health-promotion and disease prevention are as much a part of the training and preparation of chiropractic practitioners as is the diagnosis and treatment of disease.5 If there is neglect in any area of health promotion in chiropractic education, it is in the practical application of health-promotion strategies in the clinical training of interns.6 With the CCE emphasis on health-promotion and wellness competencies, it is hoped that any deficiencies in chiropractic education and training will be rectified.7
The strong predictors of access to quality health care and health promotion strategies identified by Healthy People 2010 are tied to socioeconomic status. These include having health insurance, a higher income level and regular primary-care services.1 Unhealthy lifestyles cannot be blamed solely on the victim when financial barriers limit access to health education information. It is unrealistic to expect individuals with poor nutrition,8 or who work long hours without access to healthy recreational activities to embrace health-enhancing initiatives or undertake self-care.
Studies in St. Louis have demonstrated that the spatial distribution of fast-food chains and supermarkets in minority communities (ones that actually offer good food choices) had fewer supermarket options and more fast-food outlets, no matter the income level. Without access to healthy food choices, individuals cannot make positive changes in their diets. Even if the patient consumer is well-informed, just as with health care in general, it's all about access.9
Attitude is important and successful self-care transforms a fatalistic acceptance of health problems into recognition of health as a state of personal control that improves their circumstances. Chiropractors as primary care practitioners can provide resources and serve as health educators assisting patients to acquire knowledge and skills necessary to maintain health and achieve well-being. Equally important is assisting patients to access both healthy life habits and finding access to health-promoting resources.
Health insurance coverage in the United States is a national disaster. The number of Americans without any health insurance is steadily increasing from 44 million people in the year 2000 to an estimated 47 million in 2007. Equally alarming is the number of underinsured who are denied coverage for preexisting conditions. The paper storm of prior authorization that frustrates practitioners, the policy of delay in payment and medical decisions made by non-medical personnel challenges the fortitude of the most dedicated of clinicians, as well as patients. Health insurance should provide access to routine checkups and screenings, as well as for health care. Payment for health education and preventive services rarely is included.
Perhaps the most meaningful definition of health in the last century has been from the World Health Organization (WHO). "Health is a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity."10 This definition is perpetuated in the Ottawa Charter for Health Promotion, which adds an ecological dimension.12 More than a state, health is a process, the promotion of which requires a transdisciplinary integrative paradigm.13 A key component in the WHO's strategy for health promotion is building a legitimate framework for health promotion. This requires a multidisciplinary approach and alternative paradigms that move from traditional disease-centered models to health as a resource of everyday living.
A patient-centered paradigm is necessary to promote health through which the patient is not a passive subject to whom things are done by a detached professional.12 The optimal paradigm for chiropractic education and research places great emphasis on promotion of the individual's health through an active partnership that includes instruction on lifestyle changes.13 Individuals who conceive of health as the presence of wellness, rather than as merely the absence of disease, have a significantly stronger engagement in health-promoting lifestyles.14 This patient-centered approach to health promotion is part of most alternative therapies12 and emphasized in the recommendations for health care reform by the Institute of Medicine that proposed a new health system for the 21st century.15 Access to health promotion and wellness care is dependent on a paradigm that is not strictly curative, technical, impersonal, mechanistic and expensive, as is the nature of the current medical model.
As one who has lived in a country with universal health coverage and a single-party not-for-profit payer, it boggles my mind to see and hear the blatant misinformation spewing forth by the self-interest groups who employ fear and empty rhetoric to prevent a fair and equitable health care system for all in the richest country on Earth. Health promotion and wellness, as well as health care for the profit of "greed heads" is a disgrace that is morally dishonest, reprehensible and unworthy of this great nation.
Perhaps the only solution to the dilemma is to implement a program of universal coverage that eliminates the profit of self-interest groups who employ some of the most powerful lobbies influencing government. While taking these lobbyists head-on will only delay a fair and equitable system of health care for all Americans, a system of universal coverage in which those dissatisfied with their current inadequate coverage can opt for a single non-profit plan, leaving only the very few who currently have adequate coverage to deal with the health care for-profit corporations. As numbers dwindle and there is no longer much profit to be gained from the few who are satisfied with their health care plans, then meaningful health care reform can become a reality.
There are more Americans receiving health care that is covered by a single payer through Medicare and Medicaid than there are Canadians covered in all the provinces. While this system is not perfect, the strengths of this system and others that provide universal coverage in developed countries should be studied with the goal of providing access for health promotion and wellness care for all Americans. Chiropractors who position themselves to offer health promotion and wellness education to their patients will do a service to both their patients and the profession as a whole. The chiropractic profession as a whole needs to become more involved in meeting the challenge of health care reform that places a strong emphasis on health promotion and wellness for all and is in the patient's interest.
- Healthy People 2010: Understanding and Improving Health. Washington, D.C.: US Department of Health and Human Services, November 2000.
- Ford V, Furlong B. Health systems and health promotion programs-the necessity of cultural competence: an ethical analysis. Research in the Sociology of Health Care, 2005;23:233-42.
- Kerr M. Assessment in primary care. Psychiatry, 2006;5:351-4.
- Jamison JR. Health Promotion for Chiropractic Practice. Gaithersburg, Md.: Aspen Publications, 1990.
- Christensen MG. Job Analysis of Chiropractic. Greeley, Colo.: National Board of Chiropractic Examiners, 1993.
- Anthony Rosner. Personal communication. An observation based on student interaction.
- Gatterman MI, Brimhall JE. CCE adopts Health promotion and wellness competencies. Dynamic Chiropractic, April 24, 2006.
- Position of the American dietetic association: child and adolescent food and nutrition programs. J Am Dietetic Assoc, 2006;106:1467-75.
- Baker AE. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. Preventing Chronic Disease: Public Health Research, Practice and Policy. July 2006;3(3):1-11.
- World Health Organization. A Discussion Document on the Concept and Principles of Health Promotion. Copenhagen: European Office of the World Health Organization, 1984.
- Pederson A, O'Neill M, Rootman I. Health Promotion in Canada: Provincial, National and International Perspectives. Toronto: W.B. Saunders, 1994.
- Fulder S.The impact of non-orthodox medicine on our concepts of health. In: Lafaille R, Fulder S. Towards a New Science of Health. London: Routledge, 1993:105-17.
- Gatterman MI. A patient-centered paradigm: a model for chiropractic education and research. J Alt Compl Med, 1995;1:371-86.
- Stewart M, Brown JB, Weston WW, et al. Patient-Centered Medicine: Transforming the Clinical Method. London: Sage, 1995.
- Committee on Quality of Health Care of the Institute of Medicine. Crossing The Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press, 2001.
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