September 29, 2020
When food production technology made it possible, wheat flour processors started to eliminate the tough exterior (bran) and nutrient-rich core (germ) of the kernel to get at the large, starchy part (the endosperm) only. The bread produced from this process is white and fluffy, and it makes great PB&Js and takes forever to grow mold, but it is almost totally lacking nutritional value.
Nutrition experts eventually pointed this out, of course, after which commercial bakers tried fortifying their breads by adding back essential nutrients stripped out by processing. It didn’t work. While white bread from refined flour is still available, nutrition experts strongly recommend whole grain products as the healthier alternative.
Opposition to this reductionist approach to nutrition is perhaps best captured by the idea of the sum being the whole of its parts: If inputs are lacking, the end result will fall short also.
Each human being is also a sum of parts, and the reductionist approach to healthcare is essential when it comes to advancing many aspects of medicine and healthcare.
“Historically, the invention of the microscope, the defining of Koch’s four infectious disease postulates, the unraveling of the human genome, and even intelligent computers are salient examples of the dramatic benefits of biomedical reductionism,” explained Dr. George Lundberg.
These successes, however, may have convinced many in both the medical community and society at large that reductionism is a necessary, if not sufficient, approach. The numbers say otherwise.
“Classical medical care interventions contribute only about 10 percent to reducing premature deaths compared to other elements such as genetic predisposition, social factors, and individual health behaviors,” Lundberg goes on to say. “Most contemporary medical researchers have concluded that the chronic degenerative diseases of modern Western humans have multiple contributory causes, thus not lending themselves to the single agent-single outcome model.”
Paging Dr. House. It turns out your particular form of genius just isn’t frequently that useful.
And nowhere is the single agent-single outcome model arguably less effective than in behavioral health and chronic disease management. What many in medicine and healthcare now realize is that a vicious cycle of alternating physical and mental ailments are the norm with both chronic illness and long-term mental health challenges.
“Depression and chronic physical illness are in reciprocal relationship with one another: not only do many chronic illnesses cause higher rates of depression, but depression has been shown to antedate some chronic physical illnesses,” says Professor David Goldberg of the Institute of Psychiatry in London.
It’s an unsurprisingly intuitive conclusion to reach. A man with depression lacks the desire to eat well, exercise, often practice necessary daily hygiene. As his untreated depression deepens, his physical health declines as well. A woman with chronic, untreated pain feels like it will never end and her life is over. Faced with a seemingly unmanageable challenge, she falls into a funk that eventually metastasizes into full-blown depression.
A reductionist approach to these scenarios might be to encourage more exercise or prescribe antidepressants. While both are necessary, neither will likely be sufficient.
So why hasn’t a more holistic approach to patient care become the norm? In a nutshell, because it’s expensive. Chronic illnesses, generally, are the most expensive component of healthcare.
According to a New England Journal of Medicine study, patients “with three or more chronic conditions (43 percent of Medicare beneficiaries) account for more than 80 percent of Medicare health care costs.”
For this expensive, highly at-risk group, holistic care is what actually works.
The NEJM articles concludes that “an intervention involving proactive follow-up by nurse care managers working closely with physicians, integrating the management of medical and psychological illnesses, and using individualized treatment regimens guided by treat-to-target principles improved both medical outcomes and depression in depressed patients with diabetes, coronary heart disease, or both.”
Of course, the regimen included in the NEJM study is expensive—perhaps more so than what qualifies as holistic care now.
But it requires a certain type of twisted logic to argue for holding down costs by rationing care inputs—by reductively treating only just the most obvious health concerns—when this approach invariably leads to readmissions, more office visits, more disability payments, more days of work missed.
Indeed, a reductive approach to accounting—silos of financial impact across the continuity of a life lived—hides the fact that specific healthcare costs are not alone the measure of how chronic illness detracts from both individual life satisfaction and broader societal efficiencies.
The key, then, is to make holistic health both the norm and affordable. How can that be done? By creating initiatives designed to achieve a core set of goals:
These four bullets are probably just the most obvious suggestions, of course. They don’t account for the complexities of the American healthcare system focused on payment models, the profit motive, or what to do with the uninsured, homeless and devastatingly mentally ill.
But the benefits of holistic thinking when reductionism is inadequate applies to both individual care and the healthcare system as a whole. Public health, for example, takes a holistic approach to communities by looking at how housing, transportation, and education impact general overall health. Where this approach is done well, the benefits are obvious.
Reductionist isolation will always be necessary when identifying specific genes or determining which natural elements are effective in treating disease. But it’s wise to always bring the right tools for the job.