By Wolfgang Höschele, last updated August 2013
Physical and mental health, and access to appropriate care in the case of illness or disability
Bodily and mental well-being, or health, is a basic need, without which we can enjoy little else in life. It is sometimes assumed that the availability of health-care is equivalent to meeting the need for health, but it needs to be recognized that if risk-factors are minimized, then there is less need for health-care while assuring the same level of overall health. Furthermore, many of the things we do in order to maintain our health (for example, healthy eating) are not strictly-speaking health-care. It is therefore essential to see health in a broad ecological and social context.
Context within NORA
Relationships to other needs
Clean air and water, as well as sufficient and nutritious food, are essential for health.
Being at home in the place where one lives: If one feels at home, one is more lively, one’s vulnerability to disease agents is less, one’s immune functions are likely to be enhanced, and one is able to recover from disease more quickly and completely. Being at home enhances one’s self-healing capacities.
Mobility may be needed both by patients to reach hospitals, clinics and the like, and for doctors and healers to reach patients.
Security from bodily, emotional, and mental harm: Many of the harms from which one needs to be secure are harms to health. Hence, greater security directly contributes to greater health. Greater security can also indirectly contribute to health, by allowing people to focus their entire energy to overcoming disease, without being distracted by the need to defend themselves from other threats.
Inadequate clothing and shelter/housing may lead to overexposure to environmental conditions such as cold, rain or sun, and thus ill health.
Supportive relationships with other people, relationships that empower, that contribute to a gain in personal energy rather than an energy drain, and that allow plenty of scope for self-expression, are needed for good health. Conversely, poor relationships with other people, and constraints on one’s ability to express oneself, directly create distress, and contribute to mental disease. Since mind and body are closely connected, such stress also contributes to bodily diseases, or impedes recovery from disease.
Opportunities to learn about matters pertaining to health are vital to living healthily, preventing disease, and taking the right steps to recover from disease. As in all matters of education, there can also be miseducation, that prevents people from understanding what they need to know in order to be healthy.
A livelihood (meaningful or not) is needed in order to live a healthy life (e.g., with good nutrition, shelter etc.), and in most countries is also needed in order to have access to good health care. If one feels that one’s livelihood is meaningful, one will also tend to be inclined toward more healthy choices in one’s life in general, and contribute with greater joy to the healthy living of others.
Participation in collective economic and political decision-making: Many decisions that either directly affect people’s health, or that affect the quality of health-care, must be made collectively. Such decisions affect the risks of everyday life as well as the hazards in the case of extreme events such as earthquakes and floods; they also affect how hospitals are run, who gets access to medical services, and the like. Only if all social groups can have their voices heard can it be assured that such decision-making benefits everyone.
Having enough time to relax, to think, to imagine, to enjoy life, to play, to be alone; spiritual connection with one’s deeper self and with a transcendent unity: A healthy, well-balanced, and fulfilled life includes both these aspects, without which one’s full human potential cannot be attained. True health, which means wholeness, does not exist without them.
Relationships to Organizational Forms
Health is to a considerable extent a matter of self-provisioning, because each person has to look out for his or her own health. Through community solidarity, it is possible to provide for many of the needs for health or health care. In the context of currencies and markets; it is possible to provide for health or health care needs through a combination of individual sales (e.g., sales of items needed for hygiene) and committed services or sales (e.g., long-term relationships between family doctors and their patients). Knowledge relevant to health can be made available through organizational forms of the free knowledge cluster.
Punitive or coercive measures used in the coercion/denial of choice cluster may be aimed at undermining a person’s health, up to the point of death.
Relationships to Resources
Health depends on access to clean air, water. and land. Health care requires intangibles such as knowledge and love, as well as physical, human-made assets such as hospitals with an array of specialized equipment. medicines are made using ingredients derived from living things (such as medicinal herbs) and mineral resources.
Understanding patterns of abundance and scarcity
Good health begins with healthy living conditions: clean air, clean and plentiful water, a sufficient, nutritious, and balanced diet, good shelter, and loving and supportive relationships. If widespread abundance is achieved in these areas, covered in other sections of NORA, most of the struggle against poor health will already be won.
Beyond these very basics, it is important to work toward health-promoting environments in other ways as well. It is of key importance to design cities and village such that there are few traffic deaths and it is fun and pleasurable to be outside, whether for recreation, chatting with friends, going on a walk, or getting somewhere by walking or cycling. Not only do people then engage in the physical exercise that they need, they are also more likely to feel at home in the place, and take an interest in the neighborhood.
Avoidable risks should be reduced, particularly where there is no conceivable benefit to exposure to those risks. This entails vigilance about pesticides, food additives and potentially harmful substances in cosmetics, and designing workplaces (in factories, in mines, in offices, on agricultural fields etc.) such as to eliminate hazardous conditions. Regulations in these areas are often insufficient because of the clout of the food, cosmetics, and chemicals industries, and because employers consider it a cost to take care of the safety of their workers. Greater workplace democracy, whether through strong unions or through worker-ownership of companies, helps to ensure greater respect for the needs of workers. In many jobs, the health risks come not from overt injury, but from long-term stress; a more relaxed pace of work, and more focus on collaboration rather than competition would help to reduce stress and promote health.
Widespread education about matters pertaining to health is also important, including knowledge of basic hygiene, how to deal with common illnesses, stress-reduction techniques, massage and the like. Such education should also extend to knowing what questions to ask of doctors and other healers when being treated. Education can occur both in formal instruction and through all kinds of informal means, including broadcast and print media, the Internet, and street performances. The possibilities are endless.
It is only within the above context that curative healthcare can achieve its greatest potential. Large-scale immunization can then eliminate the most pervasive infectious diseases. Skilled and nurturing care for mothers and their infants can then all but eliminate maternal, infant and child mortality. The scourges that led to low life expectancies in the past (by today’s standards, that is) can almost be done away with. Where they persist, they do so because of rampant injustice in access to food, clean water, and basic health services, and unequal exposure to a variety of hazards, many of them in and around hazardous workplaces.
Modern medicine has triumphed in combating diseases that have a clearly identifiable cause, such as viral or bacterial diseases, or where an offending organ can be simply removed, as in appendicitis. However, it performs poorly in those diseases where there are a host of risk factors but no clear cause, as in cardiovascular diseases and cancer. People with high blood-pressure are put on blood-pressure reducing medicines for the rest of their lives – this is not a cure, it just reduces symptoms. Modern medicine also fails to recognize the links between mental and physical health, and it altogether fails in treating mental illness. Mental illnesses have been increasing dramatically even while psychiatric drugs are supposedly leading to better treatments than in the past – what better proof of failed treatment than more disease with more treatment? The distrust of the “placebo effect” (the phenomenon that patients who believe they will get better often do get better) seems to have led to an effort to intentionally make patients feel bad, which reduces their chances of recovery. It can hardly be surprising, then, that more and more people are seeking treatment from “alternative” healers. The challenge to medicine is to find ways to consciously stimulate the “placebo effect” (which should more appropriately be called the patient’s self-healing capacity). This could be done through a synthesis of different healing approaches, while fostering a supportive relationship between doctor and patient.
The dominant medical institutions, however, tend to block a path toward synthesizing the best knowledge from all healing approaches. This is partly because of a model of research and knowledge that validates only a very few methods of scientific inquiry (e.g., the “double-blind” method), and a refusal to recognize that medicine must be as much a social as a natural science (and thus should learn, for example, from anthropological and sociological methods of study). Existing medical institutions have invested heavily in expensive diagnostic machines (e.g., cat-scans), that must be paid off, and that are seen as the guarantors of their scientific approach. Methods of calculating payments validate the use of such machines, and invalidate deep listening by the doctor, or careful probing about a patient’s social and psychological conditions which may do more to explain disease than any physical condition. Despite the fact that people clearly have muscles and muscle tension contributes to innumerable illnesses, massage is seen with suspicion, almost as something esoteric, instead of being incorporated into standard treatment regimes. Institutional change is required in order to allow integration of a holistic approach to treatment of illness.
This lack of integration also drives up healthcare costs. Iatrogenic disease (disease caused by the treatment of a disease) is a serious problem according to authoritative, established sources, and arises if doctors do not treat whole human beings, but focus only on diseased organs. By failing to recognize psychological or social causes of diseases, doctors fail to treat the real causes of disease (for example, those diseases caused by stress); if one such disease is “successfully” treated (or at least its symptoms alleviated), the stress will simply manifest in a different way in a different part of the body, leading to more expensive treatments.
Within this context, the high costs of medicine are a major driver of high healthcare costs. The costs of medicine are kept high as a result of patents, which are a government intervention to enable the establishment of temporary (usually 20-year) monopolies. The patents are supposedly designed to reward investments in research and development, but a large share of those costs are actually paid by government bodies (e.g., in US, NIH), which means that the public pays for research twice (first through taxes, second through monopoly prices). The R&D costs are dwarfed by advertising, especially high in the US where there is lots of direct-to-consumer advertising. A lot of the money spent on “further education” of doctors at conferences is also advertising for pharmaceuticals. Much of the R&D spending is for minor tinkering with drugs, so that when an old patent runs out, an insignificantly altered drug can be marketed as a “new” drug, at high price (with a new patent). The entire patent system furthermore leads to a focus on drug-based health-“care,” and a neglect of approaches that do not depend on drugs and do not allow patents to be claimed. There’s also no incentive to take side effects of drugs really seriously; those in fact tend to increase revenue as patients take a whole cocktail of drugs. In countries where the government takes a pro-active stance to regulate drug prices, prices may be somewhat reasonable despite patent monopolies, but where the government does not take this approach, drug prices tend to be exorbitant.
Private health insurance can also drive up the costs of healthcare, as bureaucratic costs tend to increase as the insurers second-guess the doctors and vice versa. The insurance companies often present yet another barrier to the unbiased assessment of new approaches to treatment.
These and other tendencies have led to a seemingly perpetual increase in healthcare costs, even while life expectancies are creeping up only marginally in the core industrialized countries. Progress is supposed to lead to greater efficiency (reduced costs), but here what is touted as progress is clearly leading to reduced efficiency. Private (and often public) healthcare facilities try to compensate this trend by hiring nurses and other staff at as low salaries as they can, while making them work harder. Hence, many such facilities in the core industrialized countries depend increasingly on immigrant labor.
Where healthcare is performed for profit (for-profit hospitals, insurance companies, and pharmaceutical companies), the most profits can be derived from people who are sick almost all the time, who are constantly in need of treatment and drugs, but do not die until they are quite old. This is the direction we are heading in more and more countries of the world. Instead, what are needed are healthcare institutions that benefit when people are healthy almost all the time, and tend to die in old age after a comparatively short period of illness. The challenge is to design institutions aligned in this way.
Approaches to creating greater abundance
public health programs
community health initiatives
health education programs
Youth Obesity, Nutrition Resources, and Physcial Activity
public water provision
water filtration systems for small communities and households
regulation of food additives; disclosure of additives present in food
research involving collaboration of doctors and patients
research and healing approaches that seek an integration of different knowledge traditions
Health Commons: an approach to collaborative research and sharing of results
transparency and information sharing by hospitals and doctors
social science approaches to studying disease, and treatment of disease
approaches to healing disease that involve active participation of patients, that activate the patients’ self healing capacities
WHO list of medicines that are the most essential and that are not patent-protected
laws that publicly funded research must not be patented
public health insurance
customer-owned health insurance
health insurance scheme for musicians in Austin, Texas
artabana (mutual aid system in Germany)
surely a lot more here
Research project at the Ostrom Workshop on the Health as a Commons
Links to organizations addressing health issues of the kinds addressed in this section to be added here. Links for more specialized organizations will be added on more specialized pages.
This section is to include fairly general literature relating to the institutions that affect abundance and scarcity in health and health care; literature pertaining to more specific topics will be included in more specialized pages.
Angell, M. 2004. The Truth about the Drug Companies: How They Deceive Us and What to Do About It. New York: Random House.
Humber, J. and Almeder, R. (eds.) 1998. Alternative Medicine and Ethics. Totowa, NJ: Humana Press.
Illich, Ivan. 1976. Medical Nemesis: The Expropriation of Health. New York: Pantheon Books.
Leape, L. 2000. Institute of Medicine Medical Error Figures are Not Exaggerated. Journal of the American Medical Association 284: 95-97.
Leape, L. and Berwick, D. 2005. “Five Years after To Err is Human: What Have We Learned?” Journal of the American Medical Association 293: 2384-2390.
Makary, Marty. 2012. Unaccountable: What hospitals won’t tell you and how transparency can revolutionaize health care. New York: Bloomsbury Press.
Malpani, R. and Kamal-Yanni, M. 2006. “Patents versus Patients: Five Years after the Doha Declaration”
McKeown, T., Record, R. G., and Turner, R. D. 1975. An Interpretation of the Decline in Mortality in England and Wales During the Twentieth Century. Population Studies 29: 391-422.
Spiro, H. 1998. The Power of Hope: A Doctor’s Perspective. New Haven, CT: Yale University Press.
Wilkinson, R. G. 1996. Unhealthy Societies: The Afflictions of Inequality. London: Routledge.