Erwin W. Hohn, BVSc, MRCVS, Dip PM, Dip MM, Dip MD, Dip FM, BA(Hons), MBA, FCMI
The adoption of the "One Health" concept provides the veterinary profession with opportunities to reevaluate the context of animal health care delivery systems.
It is essential to be aware of the paradigmal context within which we operate. This is because context frames how we see define problems, formulate hypotheses and even how we develop and implement solutions. In science this is probably best seen using light theory. We apply either wave or photon theory as a context and this defines our understanding of how specific systems work.1
Irrespective of how scientific our approach may be, we, as observers, are susceptible to fundamental attribution error. This means that when it comes to interpreting outcomes we tend to underestimate the importance of the situation and context. In very simplistic terms this means that were we to observe someone shooting basketball hoops in a well lit or a dimly lit hall, we would tend to attribute a low score to the skill of the player rather than poor lighting.1 The paradigmal context to which we have subscribed as veterinarians makes us equally susceptible to this even with the application of so-called scientific methodology, principally because the context limits the parameters within which we view, define, and seek solutions to problems.
As veterinarians (especially clinicians), it is important to consider who we use as our reference group. This determines the paradigmal context within which we practice our profession. With the exception of herd health practitioners, the majority of veterinarians consciously or subconsciously tend to use human medical practitioners as their reference group - and predominantly the application of a technological imperative with the development of a principally clinical curative model. Historically, this has served both us and man well.
However, it is worth noting that subscribing to this paradigm has resulted in the paradox where traditionally the physician's prestige has been measured by the depth of illness treated rather than the height of health promoted.2 This perception is unfortunately often shared by the public primarily because the use of complex and intricate technology has historically been equated with quality.3 Notwithstanding the fact that improved health as well as decreased morbidities and mortalities were encountered in developed countries before the major advances in both curative and preventive medical technologies, that received accolades.4
A good example of how the delivery of so-called "health care" within this context is limiting can be seen particularly in resource-poor communities. Traditionally, initial entry to this "market" would have been the building of a large well-equipped and well-staffed hospital. Within a short time it became apparent that this left more distant areas relatively underserved and a number of less well resourced district hospitals (DH) were introduced to improve access to care.
Particularly in poorer communities, the demand for basic clinical curative medicine, both curative and preventive became overwhelming with the resultant development of peripheral clinics (PC) each feeding into its local DH. Further demand eventually resulted in visiting points (VP) feeding into peripheral clinics with a number of village health workers (both curative and preventive) (VHW) active around their local VP (Figure 1).5
|Figure 1. A community-oriented health care system
Essentially, the availability of technologies and skills delivering clinical curative "health care" is diluted as one moves further away from the Regional Referral Hospital (RRH) and down to the VP. For "quality of care" to be achieved the system relies on the upward referral of more complex cases requiring the attention of experts.6
Since disease is a manifestation of socioeconomic predicament,5 the application of a predominantly clinical curative model by definition engenders an attitude of dependency in the communities it serves7. Paradoxically, most conditions are generally preventable at a relatively low cost.5 If this underlying problem is not addressed, demand for a curative service continues to rise, placing increased pressure, especially financial pressure, on the system for greater access and availability to health care.8
One solution to this dilemma necessitates subscribing to an empowerment philosophy. This requires shifting the locus of control for health away from that of the physician and back into the community. An important but subtle nuance that is pivotal to the success of this approach is transcending the paradigm of disease prevention and embracing the philosophy of health promotion. To do this, illness needs to be viewed as a failure of health care peripheral to the hospital, in other words a failure of primary health care. Health needs to be viewed as more than just absence of disease and should not be seen as a service commodity but rather a way of life.5,6 This is easier said than done.
In general, the strategic deployment of resources to deal with regional and national health problems lies in the hands of the specialists whose perspective rarely reflects the day-to-day realities of what happens at the coal face. This is not surprising since their universe is comprised of the roughly 0.1% of the conditions to which the population is exposed.9 These tend to represent the "exotica" of routine work load for health workers, nurses, and general practitioners.
This problem is self-perpetuating in that the predominant exposure to specialists also sets role models for the next generation of clinicians (i.e., the undergraduate students) to follow. The increasing tendency towards specialisation also results in the fragmentation of the undergraduate curriculum. Consequently, the potential to present the student with an integrated perspective risks being lost.10
For the sake of brevity this argument has been simplified but, for quite some time, within human health care there have been calls to address these and related issues through the provision of community-based and community-oriented education.5 In human health, Community Health is the discipline that has been leading this. So far, this perspective and the call for improved Primary Health Care appear to have gone largely unrecognised. Part of the problem lies in how the next generation of health care providers have been schooled and "socialised" into their profession. Learning primary care medicine in a university is like trying to learn forestry in a lumberyard (or worse still - a specialist joinery!).
Despite major technological advances in health care, poor compliance remains one of the major challenges to treatment outcomes outside of specialised care facilities. This is further evidence in support of the hypothesis that current "health care" training and provision is ill equipped to deal with issues appropriately whilst operating within the technological clinical curative paradigm.
Once again the simplistic underlying assumption is that a basic transfer of relevant information is adequate to effect an appropriate and relevant change in behaviour. Community health practitioners and marketeers have long known that efforts are required not only to impact on knowledge but also attitudes and behaviour. The last decades' successful campaigns on smoking show how more effective this approach can be. The only way communities/people will be able to assist themselves in achieving an improved health status is through an improvement in their knowledge and levels of motivation.5,6
By operating within a clinical curative framework, the successful tiering of services from RRH down to VPs with VHWs will result in operational efficiencies. An integrated and collaborative network in poorer communities will make access more affordable whilst in more affluent communities this allows for more profitable delivery. However, the relative availability of specialized skills and resources becomes less as one moves further down the hierarchy - a primary medical care approach.
To deliver true health care it is necessary to complement this curative infrastructure with an integrated, holistic, and health-promoting perspective. This requires the introduction of services offering information, advice, and support, as well as disease prevention - and, more importantly, health promotion. The availability of these services needs to be highest at the coal face viz: VP & VHW level and least at the tertiary care level (Figure 2).6
|Figure 2. Organisational levels for integrated veterinary health care
For this to work, integrated oversight as well as community, management, and epidemiological perspectives are required in addition to that of the physician. Rapid identification of relevant needs (be they health or disease based) must take place with efficient referrals both up and down the hierarchy to the relevant experts. For this to happen, health care delivery needs to be planned and managed by people with the appropriate perspective and relevant training. The role of the health professional therefore becomes transformed from a "deliverer of health" to a facilitator. One should not lose sight of the fact that this process involves a multidisciplinary-team approach and is, therefore, not cheap. There is no doubt, however, that it will be more cost effective and, in the long term, cheaper than our present option.6
In essence, our orchestra requires a conductor to ensure that we all start together and play in tune and in time. However, this call will most likely be met with resistance from the specialists and lead soloists as they may perceive that this will diminish their relevance and/or power base. Itzhak Perlman, renowned conductor and violinist, thinks otherwise: "I don't feel that the conductor has real power. The orchestra has the power, and every member of it knows instantaneously if you're just beating time."
All, or at least many, of the pieces of the puzzle are already there. All we need is the will to rearrange them appropriately and effect delivery within the appropriate contextual framework.
VIN editor: References 2 and 4 are the same.
1. Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Library of Congress Cataloging-in-publication Data; 2000.
2. Sanders D, Carver R. The Struggle for Health. Medicine and the Politics of Underdevelopment. London, UK: MacMillan; 1985.
3. Fendall R. Myths and misconceptions in primary health care. Third World Planning Review. 1985;7:307–322.
4. Sanders D, Carver R. The Struggle for Health. Medicine and the Politics of Underdevelopment. London, UK: MacMillan; 1985.
5. Spencer IWF. Community Health. Pietermartizburg: Shuter and Shooter; 1980.
6. Hohn EW, Williams JH. Veterinary Community Health: an emerging discipline. Journal of the South African Veterinary Association. 1997;68(2):32–34.
7. Wisner B. GOBI versus PHC? Some dangers of selective primary health care. Social Science and Medicine. 1987;24:1–7
8. Heggenhougen HK. Will primary health care efforts be allowed to succeed? Social Science and Medicine. 1984;19:217–224.
9. White KL, Williams TF, Greenberg BC. The ecology of medical care. New England Journal of Medicine. 1961;265:885.
10. Hohn EW, Durante EJ. A proposed curriculum for veterinary schools in developing countries. Journal of Veterinary Medical Education. 1995;22(2):56–59.