Let’s Make Sure “Health” Encompasses “Care”

Risa preferred headshotFor the past several months the Robert Wood Johnson Foundation has been promoting a particular vision– of a Culture of Health in America, where everyone  has the opportunity to live the healthiest life possible, no matter their income, or where they live, or work, or play.

With  that vision in mind, geriatrician Dr. Leslie Kernisan asks an important question in her Oct 7 Health Care Blog post, “Why #CultureofHealth Doesn’t Work For Me.”  She writes: “Is promoting a Culture of Health the same as promoting a Culture of Care? As a front-line clinician, they feel very different to me.”

For physicians treating the chronically ill and patients facing the end of life, good health might seem like a pipe dream. Kernisan and some of her commenters even wonder if the phrase “Culture of Health” could be misconstrued as “blaming the victim.”

I appreciate—and am grateful for– her concern.  I am also a geriatrician, so I understand where Kernisan is coming from. I believe that care and health are two sides of the same coin. Having a system that provides care when, how, and where people need it is a crucial component of a Culture of Health.

I had a light bulb moment early in my career when I realized that we cannot properly care for the very ill unless we address the many issues that affects their health outside the clinic’s walls.  I was doing my residency in Boston when I met a woman I will always think of as “Patient Ruth.” She appeared at my hospital’s admitting station late on a winter night, homeless and helpless, and she brought the cold in with her.

Her feet were swollen; she wore flimsy house shoes and raw leg ulcers made walking painful. Her medical chart was thick; she’d been to the hospital many times before. We did for her what the hospital always did– a few hours in a warm bed, some antibiotics, a decent meal. But the rules dictated that the next morning we had to let her go, limping back to the same problems she had before: No home, no job, lousy food, cast-off clothing, no family or friends to come to her aid.

We were bit players in a system that was not equipped to protect Patient Ruth from the harshness of life outside the hospital, a harshness that was destroying her health and shortening her life. What if, instead of ushering her back into the cold, we could have asked what she needed to keep from having to come back? And then what if we linked her to those people or services? Shouldn’t that be the aim of every medical visit?

Those questions, and the answers, are intrinsic to building a Culture of Health. Ruth is never going to run a marathon, but there are things that can be done to help her find her own “healthy”. Ultimately there is no single way to cultivate health, or offer care. Only by all of us working toward a common goal, for everyone in America — be they sick or well, just born into this world or reaching the end of life — can we truly build a nation where everyone has the opportunity to achieve their optimal health.

Risa Lavizzo-Mourey is the CEO of the Robert Wood Johnson Foundation

23 replies »

  1. This is great news, thank you!

    I hope you won’t mind if I keep brainstorming memes.




    hm…and of course there is #CultureofCare…

    Thank you once again for giving my post such thoughtful consideration.

  2. Thanks, everyone, for weighing in on this important issue. It is a great reminder of the power of language – and in recognition of the concerns discussed in Leslie Kernisan’s post, and these comments, we’ve made some tweaks to the annual Robert Wood Johnson Foundation message. To make it clearer that a Culture of Health includes everyone in the U.S., be they sick or well, we’ve added the following paragraph:

    Today most people consider good health and healthy living as activities that are consciously chosen, or something that only those who are already fit can fully achieve. But imagine a culture that empowers everyone to live the healthiest lives that they can, even when they are dealing with chronic illness or other constraints. Imagine a health care system that couples treatment with care, and considers the life needs of patients, families, and caregivers, inside and outside the clinic.

    Our goal with these changes is to reflect that a Culture of Health means everyone has the opportunity to achieve the best health possible.

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  4. The Culture of Health evolved from the personal responsibility movement of the ’70s. Its antecedents are deeply rooted in our Puritan past. It equates health with moral worthiness and virtue. And illness with moral failings. It is indeed a blame-the-victim mindset.

    It flourishes in health insurance companies and employer wellness programs. I spent two years as Director of Care Management for a state insurance company. Among other things, I oversaw the wellness programs. The punitive attitudes employees had toward ill or unfit insureds thrived like toxic weeds.

    It is always “follow the money”. “If a person is ill, it’s his or her fault and I shouldn’t have to pay for that.” Culture of Health, wellness programs, personal responsibility—all synonyms for rationing.

  5. I am very impressed by the degree of passion and engagement being shown in this discussion and by the courage of Dr. Kernisan for having started it. I know how hard it is for former or would be grantees to give feedback to a funder, because at the John A. Hartford Foundation we struggle mightily to elicit even a little bit from our community.

    I’ll just say that I saved Dr. Kernisan’s piece on THCB to reflect on because it captured so well some of the concerns that I’ve had about The Culture of Health. I am reassured by what the RWJF staff are writing, but as in everything it is actions, not words alone, that will define this new concept.

  6. This conversation has been fantastic.

    You don’t really need to hear more from various RWJF folks—we can talk about this topic all the livelong day because we’re incredibly passionate about it. We also love to see the passion in these comments—even the criticism and negative ones. It’s truly wonderful. I can’t think of a better conversation for this country to have: what does a Culture of Health mean to you?

    I’m jumping back into this particular string for one reason: I want to underscore the point that everyone’s views about this Culture of Health matter. Risa’s, Anne’s, Peter’s, Peter’s patient’s, Bobby’s, Gille’s, Leslie’s views on this Culture of Health question all matter. Just like yours and yours and yours matter, as well.

    We at RWJF have spent months and months talking amongst ourselves and with hundreds of others about this vision. We have had plenty of time to consider what a Culture of Health means to us. We can talk about what we’ve come to believe pretty strongly. You’ve heard that from RWJF leaders like our CEO and Anne. You’ve heard it from me.

    Everywhere we go, though, we’re also asking you—what does a Culture of Health mean to you? How would you build it? What parts make sense to you? What worries you? What parts don’t you like? What would it take? What part of that culture is important to you?

    Such a culture would be an enormous change for our huge and diverse nation. There’s plenty of room to agree and disagree about what it should and shouldn’t be—there has to be.

    We, at RWJF, obviously can’t build something like a Culture of Health. All we can really do is join the conversation. Beyond the talk, we will certainly help where we can—you know you can count on us there.

    But actually building the thing? Only you and you and you can do that.

  7. I look at a health as a fundamental human service. By promoting health and wellness in all policies we can, over time, shift the disproportionate spending away from disease management to prevention and wellness. No other society in the world spends as much as we do on disease care, and many have better outcomes. It is no longer economically sustainable or rational to continue doing the same and expecting a different result. Without making this shift now we will not only bankrupt the county, but reduce the availability of scarce resources to provide care (of all sorts) to the most vulnerable in our society. I believe health care is a human service and a human right. But I also believe that we are obligated to act responsibly for our wellness – to the best of our abilities. It’s time to focus more time and resources on those behaviors and actions that enable wellness and prevention. It will take time, but there is no better time than the present to build on the momentum that is gaining traction as a result of the Affordable Care Act.

  8. Anne, forgot to mention this in my comment below:

    THANK YOU for mentioning the need to care for health care providers…so important as we are part of the population at large and especially because we can’t help people very well when we ourselves are burned out.

  9. Anne, thank you for your comment. I think Gilles is getting at something very important. Even if we know that you, and Dr. Lavizzo-Mourney are incorporating a culture of better care into “Culture of Health”, we have to consider how the messaging comes across to the many who just hear the tagline, or even the core RWJF points below:

    “We believe an American Culture of Health is one in which:
    1. Good health flourishes across geographic, demographic and social sectors.
    2. Being healthy and staying healthy is valued by our entire society.
    3. Individuals and families have the means and the opportunity to make choices that lead to healthy lifestyles.
    4. Business, government, individuals, and organizations work together to foster healthy communities and lifestyles.
    5. Everyone has access to affordable, quality health care.
    6. No one is excluded.
    7. Health care is efficient and equitable.
    8. The economy is less burdened by excessive and unwarranted health care spending.
    9. The health of the population guides public and private decision-making.
    10. Americans understand that we are all in this together.”

    To me, simply replacing “healthy” with “healthier” would make a difference. For the most part I don’t help my patients be “healthy”; they’re chronically ill and disabled even when I do everything right.

    However, I can always always help them be “healthier” esp if that means allowing them to define “healthier” (which it should!) and considers their wellbeing (and not just their BP and lipids & whether they exercise according to guidelines).

    It would also help if one of those 10 key points emphasized care, and not just in the rather impersonal sounding “quality health care”, efficient health care, and “health care spending.”

  10. Anne,

    you wrote “A Culture of Health, to me, is one that doesn’t distinguish between what goes on inside and outside the walls of the health care system, but gives all of us the chance to live the healthiest possible lives.”

    RWJF deals with public health issues. What counts is not what one individual thinks, but what populations understand when presented with a term like “Culture of Health”.

    I think Peter Elias’ patient reaction should be considered seriously and much effort should be done to understand if that’s standard reaction from a significant portion of the population you are trying to reach. Anything else can easily create adverse reactions no one working in ivory towers could ever imagine.

    We can only hope that such research has been conducted before the launch of the campaign. And, if such research exists, it would be nice to see the results. It would provide much credence for the campaign.

  11. Having been a primary care doc for 20 years I understand what you are saying. the problem originates with the payment structure and RUC which is a body of specialists that determine what is important. Right now a 30 year old with a sinus infection pays me the same amount as a 60 yo with diabetes hypertension and poor kidneys. That coupled with fact that a dermatologist will make four times what i make for removing a nonsuspicous mole. The health care system is being forced to give all this special attention to the worried well because they may fill out a patient satisfaction survery on you that will adversely affect you group. if you dont see the 30 yo that woke up this morning with a sore throat you are made to feel like a evil person. The chronic disease patients will always be with us, we need better systems to care to for them and that is not a care coordinator calling them once a month but is caring physician to listen to them and develop a plan that both can live with.

  12. This discussion really spoke to me. Not only because I’ve led some of RWJF’s efforts to improve health care quality and value, but as a patient myself, and as the wife, daughter, sister and mother of loved ones who have struggled to navigate the health care system’s troubled waters. Having a system that provides care when, how, and where people need it is a crucial component of a Culture of Health. We’ve got to make the health care system work for all of us. And I do mean all of us, because half of adults in this country have one or more chronic conditions, like heart disease, asthma or diabetes. Thanks to medical advances, many Americans live for years with cancer or other conditions that, a generation ago, ended too many lives too soon. So now, more than ever before, we need to interact with the health care system, and we also need to live, learn, work and play every day outside the hospital and doctor’s office. A Culture of Health, to me, is one that doesn’t distinguish between what goes on inside and outside the walls of the health care system, but gives all of us the chance to live the healthiest possible lives. There’s no question that our health care system is on the critical list. It threatens our economic viability. We know that patients aren’t getting the care they need (or deserve). Their family and caregivers are often left out of the equation. But just as important, physicians, nurses, and other health care providers are overworked and demoralized. Many of them speak wistfully of having lost touch with the inspiration that led them into health care in the first place. They feel powerless when their patients struggle with the many factors – unemployment, homelessness, the threat of violence, hunger, lack of educational opportunity – that the health care system can’t fix but have everything to do with how healthy we are. I’ve really come to believe that our focus on a Culture of Health will actually make the health care system more effective and responsive, one that that brings joy to the people who care for us.

  13. let the ill go ahead and die they are a drain on the system, and might as well kill off those born with any sort of genetic defect they will only cost us more money as well, and lets see if we can produce a genetically pure race that has no illness as well ie margarat sanger and adolf hitler

  14. I understand Bobby, I take care of some of those work-related accidents. We do need a medical system for the sick and injured. We just need to focus the resources in the right place.

  15. Assuming they do not get involved in accidents. BLS reports ~3 million employment-related accidents per year alone, 95% of them non-fatal. Add to that non-workplace related, you still have a lot of need for a medical system.

  16. I was referring to the 2014 President’s message here: http://www.rwjf.org/en/about-rwjf/annual-reports/presidents-message-2014.html

    It talks about being and staying healthy, but doesn’t speak to the people who are ill and struggle for even some improvement in health, let alone those who just want dignity and comfort because health is no longer an option for them.

    I think I understand the intent: a society that values the things that foster health. But the message I hear (and my patient heard) is that health is not just the goal, but the only acceptable state. That’s pretty hard on the ill. It lends itself to a culture of blaming patients for their misfortunes, something I see on a regular basis.

    How does a dying patient related to a culture of health? Probably by feeling alienated, disrespected and disposable. How will clinicians behave in a medical culture of health? Will they be unwilling to care for patients who cannot become healthy or do not try hard enough (by someone’s definition) to get healthy?

    I fear that a culture of health would make it less acceptable to care about those who are not healthy.

  17. Peter, not sure just what you read on RWJF site, but that is quite a response from your patient!

    What do you think of “Culture of Better Health?” (I’d love to have “caring” in there too, but trying to stay concise.)

    I feel like no matter what a person’s health situation, they and others can help make it better…for ex hospice improves the health of dying people, because it improves their wellbeing and their family’s wellbeing, and wellbeing is a core part of health. Walkable neighborhoods help make health better for people who are obese and have diabetes. And so forth…

  18. I read the piece on the RWJF site with considerable dismay.

    While the goal of a society committed to equal opportunity for health is unassailable, the language of the essay is exclusionary. Seriously and hurtfully so. The vision has no room for people who are ill.

    I showed it to a patient today: mid-30s, never-smoker, former endurance athlete, now struggling with chronic medical problems resulting from peri-operative complications from a repeat c-section. Her description: it’s like giving a short, obese person of color a brochure for a summer camp with pictures of tall, thin, Nordic athletes. Looks nice, but I don’t belong there.

    I doubt this was the intent, but I think the RWJF needs to (1) rewrite this to include acceptance of, and a role for, those who are not blessed with health; and (2) apologize for excluding those not fortunate enough to be healthy.

  19. “I had a light bulb moment early in my career when I realized that we cannot properly care for the very ill unless we address the many issues that affects their health outside the clinic’s walls.”

    ~90% of health/wellness originates in the myriad (and frequently overlapping) “upstream” headwaters. I write about that a lot on my KHIT blog.

    BTW, I’m the one who aired the “Blaming the Victim” concern. See my post about the “Rescue-Victim-Persecutor triangle.” http://bgladd.blogspot.com/2012/04/socioeconomic-drama.html

    Politically, the U.S. has gotten pretty deep into the “Persecutor” phase across a variety of fronts in recent years. The ostensible “failures” of “liberalism” are increasingly seen as license to become hard-hearted and persecute the halt and lame.

  20. Dr. Lavizzo-Mourney,

    Thank you for taking the time to read my post and to write this thoughtful response.

    Clearly we want the same type of care for people once they are unwell: care that is caring, comprehensive, coordinated, addresses the Unmentionables, leverages other disciplines and the power of communities, addresses the wellbeing of the family unit, is in line with the person’s preferences and goals, and so forth.

    We even have bright spots of this care, in certain primary care medical homes, and hopefully we’ll see access to this care increase soon.

    Yes we can frame this as promoting health. But I’m still going to hope for a complementary meme.

    Culture of Caring & Better Health?
    Culture of Optimizing Health & Wellbeing?
    Culture of Comprehensive Health Care?

    Thanks again for your post.