Like many doctors just out of residency, I found myself looking for moonlighting jobs when I entered private practice. Educational loans and rent wouldn't wait for the world to beat a path to my door. A friend told me about a job assessing disability claims, good pay and no patient responsibility. I was offered an interview, over lunch, and I was happy to oblige.
My interviewer was an elderly man, probably past retirement age, supplementing his pension. He started off with the standard question: "And why did you go into medicine?" I could hear the unspoken "young lady." Undaunted, I trotted out the same answer I had used (with less and less conviction) since my medical school interviews: "Oh, I liked science and I wanted to help people . . ." Suddenly, it struck me that while I was still an applicant, I was also a board-certified internist, theoretically this man's peer. I decided to turn the tables. "And you, Dr. Jones?"
He looked me straight in the eye and answered, "Because I was afraid of dying." He paused for emphasis. "Like everyone else."
The concept of wellness, like Dr. Jones, confronts head-on the underlying reason why we are concerned about our health. A new book, The Wellness Encyclopedia, put together at the University of California at Berkeley and published by Houghton Mifflin, defines wellness as "the optimum state of health and well-being achieved through the active prevention of illness." This is no mere passive state of not being sick. Wellness takes health a step further, to an "optimum" intended to build health credit for the future. In case the message is not clear enough in the definition, the first section of The Wellness Encyclopedia is "Longevity."
Where did "wellness" come from? Not from the medical establishment, although individual doctors have embraced the concept. Physicians by and large define their role as the diagnosis and treatment of disease. Certainly this is how we are trained. I remember sitting next to a cancer specialist in a lecture on preventive medicine when the speaker started talking about the use of seat belts. My neighbor leaned over and whispered, "Ten years of postgraduate education and they want me to tell people to buckle up?" The Wellness Encyclopedia and the newsletter from which it grew are publications of UC-Berkeley's School of Public Health, not the medical school. The majority of the editors are not physicians.
Wellness represents the convergence of several trends. The ghosts of Adele Davis, Nathan Pritikin, the Rodales, father and son, and even Jack LaLanne whisper through the nutrition and fitness chapters, "I told you so." The pugnacious self-reliance of the women's health movement is echoed in the editorial tone. "It is becoming increasingly clear that the promotion of health and the prevention of disease is an interactive process involving the development of public policy and governmental actions and the empowerment of individuals to take control of their own well-being." Norman Cousins, Hans Selye, the human potential movement, and transcendental meditation stand behind the discussions of stress and mind-body interaction. The triumph of the Wellness Letter over the years has been the editors' willingness to examine practices that fall out of the mainstream, evaluate them with common sense as well as science, and offer recommendations as to their usefulness.
Of course, preventive medicine has strong academic roots in the discipline of public health as well. Until recently, however, public health officials, like doctors, were more concerned with keeping disease at bay than changing life-styles. Today, with improved sanitation, vaccines, and antibiotics, infectious diseases (AIDS excepted) are not the threat to affluent cultures that they used to be. It is the afflictions of unknown cause--cancer, heart disease, arthritis, and diabetes--that catch up with us in the end. Since doctors can't cure these diseases, the epidemiologist, who can at least identify risk factors that predispose a person to illness, assumes a greater role. The limitations, not to speak of the expense, of "halfway technologies" such as organ transplants and coronary bypass grafts have become painfully obvious to everyone. The wonder is that it didn't happen sooner. If a city manager handled every traffic jam in a major artery by building a road around the blockage, we would dismiss him as crazy. Yet that is exactly what coronary artery bypass surgery accomplishes for the individual. It is a stopgap procedure, at best only halfway toward a cure.
So now instead of a home reference book that helps us identify signs and symptoms of specific diseases, we have a volume that instructs us in how to pursue a healthy life-style, following the current recommendations of organized medicine. This book is not a compendium of alternative therapies. Neither chiropractic nor homeopathy are listed in the index. Variety in diet, moderation in exercise, the guidelines of the American Heart Association and the American Cancer Society. There's nothing too radical here philosophically.
Not much exhorting or condemning, either. The tone is pleasantly conversational, like a good friend with no ax to grind. The scope of the material is impressive. A large-format book of over 500 pages, The Wellness Encyclopedia is divided into five major sections: Nutrition, Exercise, Self-Care, and Environment and Safety in addition to Longevity. The editors stop short of providing recipes, but practical advice in choosing individual foods complements the more general treatment of nutrients. There are tables comparing the nutritional content of breads and the difference in fat content between choice and select beef.
In every section, media controversies of the past ten years are explicitly addressed. In the Nutrition section the editors assess the aflatoxin threat in peanuts, in Self-Care they marshal the evidence supporting DPT vaccinations for children, and in Environment they highlight Lyme disease. The special attention to subjects previously mangled in the media is one of the most valuable features of the book. Then there are answers to questions your doctor doesn't have time for, like how alcohol impairs driving performance, and answers to questions your doctor is unlikely to know, like "alternatives to common cleaning materials." Imagine a collaboration of doctors, physical therapists, psychologists, environmentalists, nutritionists, and grandmothers, and you will begin to appreciate the breadth of expertise represented here.
Given the prestige of the School of Public Health at Berkeley, The Wellness Encyclopedia is certain to set a standard in both scope and content for discussions on the subject. There are physicians who maintain that wellness is just another name for the kind of preventive health the conscientious practitioner has always advocated, but I disagree. Self-care shifts the balance of power in the doctor-patient relationship, particularly when the patient sets the goals. Nutrition, exercise, and stress management, the core of wellness, have previously been on the periphery of medicine, more the province of allied health professionals. Even our traditional method of payment for health care, indemnity insurance, kicks in only when there's a problem. Health maintenance organizations emphasize prevention more, but when they set rates they calculate how much illness they'll have to treat in a given population and balance that loss against profit from the well. The radical aspect of wellness lies in its threat to the slothful American way, where "leisure" has come to mean pigging out in front of the TV. The editors of The Wellness Encyclopedia are careful to avoid spelling out the full implications of their advice: that if their suggestions were adopted by a significant portion of the population, consumer culture might collapse.
So far, we are in no danger of widespread social change; wellness represents only the top tier of our many-tiered health care system. Well-educated and well-heeled patients who can afford a week at a Pritikin center and a health club membership can simply bypass traditional health care. At the other extreme are the less savvy health consumers, the younger and poorer, who are not members of the wellness movement although they have the most to gain by joining. An article in the March 1991 Western Journal of Medicine repeats the dismal statistics: "Obesity among children aged six to eleven years has increased 54 percent in the past twenty years." "Smoking prevalence among poorly educated persons has scarcely diminished." "Average serum cholesterol levels declined between 1960 and 1980 for whites but not for blacks." In some cases, such as the prevention of osteoporosis, intervention before age 35 is critical. Yet it is teenagers who skimp on calcium while their bones are forming and older women who take calcium supplements (though it's not clear calcium alone helps much past menopause).
Every health care provider has educational materials for patients, but information is not enough to foster wellness. I think of the time I tried to demonstrate stretching exercises to a bus driver who was complaining of neck stiffness. She looked at me coolly and said, "I'm not doing anything else for those people." To practice wellness behavior, people have to believe that they have the power to change their fate. Empowerment doesn't just happen; it must be nurtured in the child and reinforced in the adult. There is a parallel here with the crisis in education, where public schools are foundering and private schools prospering. We are slowly learning that in order to educate those who perceive themselves to be disenfranchised, we must directly address self-esteem and family life, tasks that lie outside the strict boundaries of instruction. Similarly, teaching wellness would surely involve social strategies beyond handing out pamphlets. But in today's economic climate, where 37 million Americans lack access to medical care, there is little emphasis on long-term planning for wellness.
The middle American and his doctor, caught between rising expectations of wellness and the reality of a crisis-oriented health care system, can have some pretty frustrating encounters. Patients who want their cholesterol checked twice a year even though it's under 200, weekend hikers who want to "rule out Lyme disease" because their knee is stiff, and asymptomatic 40-year-olds with low cardiac risk factors who request exercise stress tests to "see where I am" are stretching the seams of insurance coverage. Physicians call them the "worried well" and find it tough to focus on their concerns during harried days filled with patients who are ill here and now. Health economists point out that "semiannual cholesterol testing for 60 million Americans at an average cost of $20 per person is $2.4 billion in laboratory work each year, not to mention several billion dollars more in physicians' visits." It took legislation to force insurance companies to pay for routine mammograms: only recently has Medicare authorized payment for flu shots.
The problem is that while some preventive interventions, like stopping smoking, are cheap and powerful, others, like mammograms, are powerful but not cheap, and still others, like cholesterol control, may be neither. The estimated gain in life expectancy of treating high cholesterol in men starting between ages 35 and 40 seems to be about seven months, and it decreases with age. Physicians are increasingly asked to weigh the marginal benefit of preventive testing for the individual against the goal of restraining overall health care costs. Should I have to pay (through increased insurance premiums) for my neighbor's "optimum" health? What is a reasonable price for wellness?
A nurse practitioner once explained to me, "My job is to teach them about menopause. If they're bright, and they can get it in 15 minutes, fine. If not, I have to see the next patient anyway." This is the dilemma all health practitioners face, which can only be solved by more creative outreach methods than one-on-one encounters with professionals trained to treat illness. We have seen some progress: taxes on cigarettes and a limitation of cigarette advertising; seat belt laws; more accurate over-the-counter tests for pregnancy and strep throat; stress classes and fitness centers in the workplace; a flood of popular literature on every aspect of health; more prescription medications released for over-the-counter sales; safe-sex and "just say no" campaigns. These population-wide interventions, while often controversial (like helmet laws for motorcyclists or gun control), work wonders. There is still a role for physicians: smoking cessation studies have shown that a warning from an MD carries more weight with patients than educational material. But the healthy young adult is rarely a patient.
Is there a downside to wellness? Certainly there can be a fine line between concern for one's health and neurosis. We all know at least one fitness nut so entranced by his own body he drives everyone except fellow fanatics away. To those so inclined, wellness is another opportunity for obsessive-compulsive behavior. As long as they are happy charting their fat calories or their mileage, no problem. But I worry about my patients who seek a guarantee of longevity. Statistically, the fit live longer. But as individuals, we cannot escape our rendezvous with death--not by a medical education, as Dr. Jones discovered, and not by wellness. A middle-aged woman once came to see me because she was feeling a little tired. When I listened to her chest, there was an unexpected dullness, and a chest X ray showed fluid. She wanted to hear the possibilities immediately, although only a sample of the fluid would reveal the diagnosis. I tried to list them neutrally--"infection, congestive heart failure, cancer"--but she interrupted me after "cancer" with a list of her own. "I practice yoga every day, I walk five miles three times a week, I eat a very low-fat diet, mostly grains and vegetables, I never smoked"--as though these choices were talismans to ensure immortality. The cells in the fluid were malignant.
On my bookshelf my oldest and newest medical books sit side by side. The oldest is a newsprint copy of Our Bodies, Ourselves by the Boston Women's Health Collective, which I bought in college. The price on the front is 35 cents. The latest is The Wellness Encyclopedia, which costs somewhat more. Both books are topical and full of great information. The difference is that 20 years ago, women, at least, spoke of "our health." But the newer book speaks of wellness as "the optimum state of health and well-being that each individual is capable of achieving, given his or her own set of circumstances" (italics mine). The wellness philosophy has the potential to energize public policy, but it also risks degenerating into an elitist cult. If only we could incorporate wellness principles into economic reforms aimed at increased access to care. Dream a little dream for me.
The Wellness Encyclopedia by the editors of the Wellness Letter, Houghton Mifflin, $29.95.
Art accompanying story in printed newspaper (not available in this archive): illustration/John Figler.