Johannes Bircher

Defining health by addressing individual, social, and environmental determinants: New opportunities for health care and public health

The Millennium Development Goals (MDGs) mobilized global commitments to promote health, socioeconomic, and sustainable development. Trends indicate that the health MDGs may not be achieved by 2015, in part because of insufficient coordination across related health, socioeconomic, and environmental initiatives. Explicitly acknowledging the need for such collaboration, the Meikirch Model of Health posits that: Health is a state of wellbeing emergent from conducive interactions between individuals’ potentials, life’s demands, and social and environmental determinants. Health results throughout the life course when individuals’ potentials – and social and environmental determinants – suffice to respond satisfactorily to the demands of life. Life’s demands can be physiological, psychosocial, or environmental, and vary across contexts, but in every case unsatisfactory responses lead to disease. This conceptualization of the integrative nature of health could contribute to ongoing efforts to strengthen cooperation across actors and sectors to improve individual and population health – leading up to 2015 and beyond.

Maze patrolling, open-field behavior and runway activity following experimental portacaval anastomosis in rats

Abstract Surgical construction of a portacaval shunt in patients with debilitating liver cirrhosis is frequently followed by the development of hepatic encephalopathy, characterized by severe cognitive and neuromuscular abnormalities. The rat with a portacaval anastomosis provides a heuristic animal model for the biochemical consequences of the portosystemic diversion of the circulation; the behavioral effects of such shunting were studied in the present investigation. The spontaneous behavior of male Sprague-Dawley rats with a chronic experimental portacaval anastomosis (end-to-side) was evaluated in a complex enclosed maze, an illuminated open field and an enclosed hexagonal runway. There was little evidence that portacaval shunted rats differed from sham operated rats in total activity, explored area, maze-center entry, or in either of two indexes of the efficiency of patrolling within a complex Dashiell-type maze over 13 successive days with three different maze configurations. Similarly, experimental and control rats did not differ in any of several responses assessed in an illuminated open field. However, rats with a portacaval shunt were hypoactive in a runway test given two months postsurgery. All experimental subjects were verified to have an open portacaval shunt and to have sustained significant liver atrophy. These results emphasize the subtle nature of the behavioral effects resulting from the surgical construction of a portacaval anastomosis in rats.

Exaggerated consumption of saccharide solutions following experimental portacaval anastomosis in rats.

Male Sprague-Dawley rats were subjected to end-to-side portacaval anastomosis and permitted to recover from the acute effects of this surgical procedure. Subsequently, portacaval-shunted rats consistently drank abnormally large quantities of 5% (W/V) solutions of glucose, fructose, and sucrose in 24-hr two-bottle tests with water present as the second fluid. The volume of glucose consumed was not altered when the concentration was increased from 5 to 10%. The pattern of preferences exhibited by the portacaval-shunted rats was similar to that of the sham-operated rats, even in three- to five-choice preference tests with several palatable fluids available simultaneously. However, no abnormally high consumption of either water- or quinine-adulterated sucrose solution was noted. Although exaggerated consumption of 0.1% sodium saccharin was not observed in the present study, subsequent unpublished research indicates that when portacaval-shunted rats are given a 0.06% sodium saccharin solution in a preference test, overconsumption relative to control rats occurs. Portacaval shunts were verified both by anatomical examination and by determination of hepatic and testicular atrophy at the conclusion of the investigation. The evidence suggests that over-responsiveness to a palatable taste underlies this phenomenon of exaggerated saccharide consumption.

Understanding the nature of health: New perspectives for medicine and public health. Improved wellbeing at lower costs

Background: Current dilemmas of health care systems call for a new look at the nature of health. This is offered by the Meikirch model. We explore its hypothetical benefit for the future of medicine and public health. Meikirch model: It states: “Health is a dynamic state of wellbeing emergent from conducive interactions between individuals’ potentials, life’s demands, and social and environmental determinants.” “Throughout the life course health results when an individuals’ biologically given potential (BGP) and his or her personally acquired potential (PAP), interacting with social and environmental determinants, satisfactorily respond to the demands of life.” Methods: We explored the Meikirch model’s possible applications for personal and public health care. Results: The PAP of each individual is the most modifiable component of the model. It responds to constructive social interactions and to personal growth. If an individual’s PAP is nurtured to develop further, it likely will contribute much more to health than without fostering. It may also compensate for losses of the BGP. An ensuing new culture of health may markedly improve health in the society. The rising costs of health care presumably are due in part to the tragedy of the commons and to moral hazard. Health as a complex adaptive system offers new possibilities for patient care, particularly for general practitioners. Discussion: Analysis of health systems by the Meikirch model reveals that in many areas more can be done to improve people’s health and to reduce health care costs than is done today. The Meikirch model appears promising for individual and public health in low and high income countries. Emphasizing health instead of disease the Meikirch model reinforces article 12 of the International Covenant on Economic, Social and Cultural Rights of the United Nations – that abandons the WHO definition - and thereby may contribute to its reinterpretation.

Will the Meikirch Model, a New Framework for Health, Induce a Paradigm Shift in Healthcare?

Over the past decades, scientific medicine has realized tremendous advances. Yet, it is felt that the quality, costs, and equity of medicine and public health have not improved correspondingly and, both inside and outside the USA, may even have changed for the worse. An initiative for improving this situation is value-based healthcare, in which value is defined as health outcomes relative to the cost of achieving them. Value-based healthcare was advocated in order to stimulate competition among healthcare providers and thereby reduce costs. The approach may be well grounded economically, but in the care of patients, “value” has ethical and philosophical connotations. The restriction of value to an economic meaning ignores the importance of health and, thus, leads to misunderstandings. We postulate that a new understanding of the nature of health is necessary. We present the Meikirch model, a conceptual framework for health and disease that views health as a complex adaptive system. We describe this model and analyze some important consequences of its application to healthcare. The resources each person needs to meet the demands of life are both biological and personal, and both function together. While scientific advances in healthcare are hailed, these advances focus mainly on the biologically given potential (BGP) and tend to neglect the personally acquired potential (PAP) of an individual person. Personal growth to improve the PAP strongly contributes to meeting the demands of life. Therefore, in individual and public health care, personal growth deserves as much attention as the BGP. The conceptual framework of the Meikirch model supports a unified understanding of healthcare and serves to develop common goals, thereby rendering interprofessional and intersectoral cooperation more successful. The Meikirch model can be used as an effective tool to stimulate health literacy and improve health-supporting behavior. If individuals and groups of people involved in healthcare interact based on the model, mutual understanding of and adherence to treatments and preventive measures will improve. In healthcare, the Meikirch model also makes it plain that neither pay-for-performance nor value-based payment is an adequate response to improve person-centered healthcare. The Meikirch model is not only a unifying theoretical framework for health and disease but also a scaffold for the practice of medicine and public health. It is fully in line with the theory and practice of evidence-based medicine, person-centered healthcare, and integrative medicine. The model offers opportunities to self-motivate people to improve their health-supporting behavior, thereby making preventive approaches and overall healthcare more effective. We believe that the Meikirch model could induce a paradigm shift in healthcare. The healthcare community is hereby invited to acquaint themselves with this model and to consider its potential ramifications.

Teaching of health with the Meikirch model to indigenous people improves their health-supporting behavior: A pilot study

Background: In a number of indigenous villages in Orissa, India, the possibility was explored that teaching of a new definition of health, the Meikirch model, might improve health behavior of inhabitants beyond what can be achieved by ordinary teaching. Methods: For this purpose, teaching about the Meikirch model was given in twenty experimental villages and conventional teaching about health in twenty control villages. Results: After 2½ years, health behavior in the two groups of villages was compared. Improvement of nutrition, wearing of slippers during use of latrines, washing of hands before meals, availability of latrines, childhood vaccination, use of mosquito nets, and attention to mother/child care were much better in experimental than in control villages (all P Conclusion: It is concluded that the Meikirch model was understood by the inhabitants of the villages and they improved their health behavior. These preliminary results justify formal studies with larger samples to validate the results and possibly to improve teaching methods.

Multimorbidity as the manifestation of network disturbances. From nosology to the Meikirch model.

The explanations of “multimorbidity” as manifestation of network disturbances by Joachim Sturmberg and his coworkers give a very interesting and comprehensive description of “multimorbidity” from the perspective of the whole chain of mechanisms that may be involved, ie, from the genome up to the biological level and from the human scale to the level of individuals, environment, and society. It becomes evident that in “multimorbidity” very large ramifications of interacting phenomena occur in different fields and relate with each other in a complex manner. This leads to a highly individualized picture characterizing in detail each persons ownhealth or disease even beyond its physical aspects. In viewof the complexity of the clinical picture in patients with “multimorbidity” it is certainly justified to approach each case with a systems‐based method. The question remains, however, whether or not it is needed and possible to develop the whole diagnostic picture frommolecular genetics to the person and its surroundings in each case. This commentary has the purpose to explore the possibility to analyze patients in a more focused manner by raising the following question: Is it possible to do the best for the patients, when applying a recently described model of health and disease, the Meikirch model? Can it identify the factors that are predominant in rendering a patient diseased, and can it help the patient to evolve further and to emerge into a better state of health? This method also gives a single picture instead of a nosological analysis of many diagnoses. For this purpose, the Meikirch model must be theoretically convincing and applicable in the practice of the care for patients with multiple diseases. This text has the purpose to describe the model, to explain its application to “multimorbidity,” and to compare it with the network model described by Sturmberg et al.

Applying a complex adaptive system's understanding of health to primary care.

This paper explores the diagnostic and therapeutic potential of a new concept of health. Investigations into the nature of health have led to a new definition that explains health as a complex adaptive system (CAS) and is based on five components (a-e). Humans like all biological creatures must satisfactorily respond to (a) the demands of life. For this purpose they need (b) a biologically given potential (BGP) and (c) a personally acquired potential (PAP). These properties of individuals are embedded within (d) social and (e) environmental determinants of health. Between these five components of health there are 10 complex interactions that justify viewing health as a CAS. In each patient, the current state of health as a CAS evolved from the past, will move forward to a new future, and has to be analyzed and treated as an autonomous whole. A diagnostic procedure is suggested as follows: together with the patient, the five components and 10 complex interactions are assessed. This may help patients to better understand their situations and to recognize possible next steps that may be useful in order to evolve toward better health by themselves. In this process mutual trust in the patient-physician interaction is critical. The described approach offers new possibilities for helping patients improve their health prospects.

IMPACT ON HEALTH ECONOMY OF A NEW THEORETICAL FRAMEWORK OF HEALTH: THE MEIKIRCH MODEL

T landscape of healthcare delivery in the United States is changing at a rapid pace with the introduction of The Affordable Care Act of 2010 (ACA). The new insurance exchange marketplace is expected to provide over 25 million uninsured with a low-cost coverage. ACA’s extension of eligibility for Medicaid to adults with incomes less than 138% of the federal poverty level has enabled states to cover an additional 13 million people through Medicaid expansion. The sizable expansion of the potential patient base has called for new and innovative approaches to healthcare delivery – approaches that are focused on cost reduction coupled with increased access to high-quality care. A cost-efficient care delivery approach requires building a solid provider workforce to specifically meet the ambulatory and primary care needs of the population and to avoid preventable hospitalizations and expensive emergency visits. Improved communications through health information technology across a wider spectrum of provider types and between patients and providers, effective implementation of a multitude of delivery models, such as the patient-centred medical home model, nurse-managed health centre model, and team-based approach to care coordination are some of the key initiatives under consideration as possible candidates for future mode of cost-efficient delivery. The new models, however, are sustainable if and only if they pass the economic cost-benefit tests as per the guidelines prescribed by the Office of Management and Budget (OMB). Health economists, with training and experience in evaluating the economic impacts of these initiatives, can play a critically important role in helping policymakers with appropriate policy prescriptions that have economy-wide implications.