Medicine Is a Social Science in Its Very Bone and Marrow

Rudolf Virchow is perhaps most widely remembered in medical circles as the father of cellular pathology,1 and researchers at Mayo Clinic are perhaps most widely renowned for their outstanding ability to translate cellular and subcellular science into practice. Readers of this editorial may be surprised to learn that Rudolph Virchow was an anthropologist. Readers may also be surprised that an anthropological study, directed by Mayo Clinic researchers, appears in this issue of Mayo Clinic Proceedings.2 Seeking to better understand the “experience” aim of the triple aim (to simultaneously improve the health of individuals and populations, improve patient experience with health care, and control costs),3 investigators at the Mayo Clinic Center for Innovation conducted an ethnographic survey in a Southeastern Minnesota city to learn how its members view their interactions with the health care sector and how they conceptualize health and well-being. Anthropologists recognize that there are 2 distinct perspectives from which to describe the experience of an individual. One is from the perspective of the observer (the “etic” perspective), and the other is from the perspective of the observed (the “emic” perspective).4 Most observations in the health sciences are from the etic perspective: telling communities their rates of various diseases or telling individuals that they have one or another disease or a particular level of a risk factor. These data are viewed as “hard” because they are statements of fact that can be tested to determine whether they are true. By contrast, the Mayo Clinic investigators adopted an emic perspective in their study of patient experience. It is not uncommon that emic data are viewed as “soft” and less desirable than etic data because they cannot be tested to determine whether they are true. Another reason that physical scientists may be uncomfortable with emic data is that the data may reveal a world view that is very different from the world view of physical science. The findings of the Center for Innovation research team may provide yet another surprise for some readers. Members of the community who were interviewed tended to view the health care system as inflexible, intimidating, and guarding of information that they thought should be shared. The investigators discovered that the health care interaction that community members value the most as patients is a relationship with a particular professional who is nurturing and makes dialogue possible—they want to be known as a whole person by someone with whom they can hold a conversation. 973 Among the important insights about community members’ conceptualizations of health and well-being, the research team found that the goals expressed by members of the community are social goals, not biological goals. “Health” for members of the community is not defined as the medical community defines it, that is, as the absence or presence of disease, a risk score, or a score of comorbidity. Instead, community members defined “health” as the ability to meet the needs of the people who depend on them. To be healthy is to be able to meet one’s social obligations. Likewise, being “well” means having a high quality of life. Anthropologists who work with community development programs distinguish between community members’ wants and needs.5 “Wants” are defined as desired states of affair and “needs” as the actions that must be taken or the conditions that must be fulfilled if wants are to be achieved or maintained. For example, an individual who wants a new car needs the money to buy it. Regarding health, people who want to remain healthy for the longest possible time need to adopt a healthy lifestyle. Although members of this community want to be healthy so that they can fulfill their social responsibilities and experience a high-quality life, they may be unaware of the needs they must satisfy to maintain the achievement of their wants over the long term. Alternatively, they may be aware of their needs but may not understand how to satisfy them while under the pressure of conflicting social expectations, time demands, economic challenges, or a physical environment that precludes addressing their needs. Which explanation dominates the community psyche needs to be explicated with further research. Both the ability to meet the expectations of others and to achieve optimal quality of life require physical and psychological health; without physical and psychological health, it is impossible to maintain optimal social functioning. The leading threats to sustained physiological health in the United States and internationally are poor nutrition, physical inactivity, use of tobacco and exposure to tobacco smoke, and hazardous use of alcohol.6-8 These behaviors are root causes of heart disease, stroke, many cancers, chronic lung disease, type 2 diabetes, and obesity, among other conditions. What people eat, the extent to which they are physically active, whether they smoke, and if/how they use alcohol are determined by opportunity and social learning. Within the bounds of opportunity, behaviors and ideas that are consistent with those that are broadly held by society are reinforced; behaviors and ideas that are in conflict with those that are broadly held by society are punished.9 It is as Clifford Geertz10 observed succinctly: “Man is an animal suspended in webs of significance he himself has spun. I take culture to be those webs,....” The observation in the Framingham cohort that both happiness and obesity spread through social networks supports these assertions.11,12 Thus, over time, children grow up to adopt the beliefs and values of their parents and the rest of the community they live with. In addition to shared visions of optimal community design, shared visions of what constitutes “good food,” how leisure time is best used, whether tobacco is used to cope with daily life, and if/how alcohol is used have a powerful influence on the behavior of individuals. These behaviors, in turn, have a powerful influence on the ability of individuals to achieve their wants to be healthy and to experience well-being: nearly 40% of all premature deaths in the United States can be attributed to the 4 behaviors in this list,6,7 and internationally, 2 of every 3 deaths are due to the chronic diseases caused by these behaviors.8 One of the challenges of medicine is to help individuals practice the necessary lifestyles to achieve their personal wants. The title of the book edited by John H. Knowles in 1977, Doing Better and Feeling Worse: Health in the United States,13 is evidence that, even 35 years ago, there was a perception that medical technology was not delivering what Americans were expecting from their health care system. The Mayo Clinic Center for Innovation investigators have provided valuable information about how individuals view the health care system and what they would like to receive from it. The insights that their investigation provides about how people think about health and well-being are valuable. However, their report says little about how the beliefs that the community holds in common (and the social networks that both support and restrain individual community members) provide opportunities for people to remain well vs to increase the risk that they will unnecessarily become ill. Investigation into these relationships will be required if the root causes of chronic diseases are to be addressed and mitigated by Mayo Clinic. When Rudolf Virchow was sent to Upper Silesia in 1848 to investigate the source of a raging typhus epidemic, he concluded that the root causes of the epidemic were poor housing, hazardous working conditions, poor diet, and lack of sanitation.14 In the next year he wrote, In reality, if medicine is the science of the healthy as well as of the ill human being (which is what it ought to be), what other science is better suited to propose laws as the basis of the social structure, in order to make effective those which are inherent in man himself? Once medicine is established as anthropology, and once the interests of the privileged no longer determine the course of public events, the physiologist and the practitioner will be counted among the elder statesmen who support the social structure.15 He then quoted his contemporary, Salomon Neumann,16 “‘Medicine is a social science in its very bone and marrow’....”17 The tools of 21st century medicine include anatomy, physiology, pharmacology, genomics, proteomics, and the related sciences, but it is only when social science is added to the tool box that medicine gains the ability to understand and respond to the wants and needs of individual patients, social networks, and whole communities. Anthropological inquiry may be strange and foreign to biological scientists because, to quote Geertz10 again, anthropology is “not an experimental science in search of law but an interpretive one in search of meaning.” I am pleased that the Mayo Clinic Center for Innovation has begun to use the tools of anthropology to better understand the meaning that their patients attribute to their lives, because through this inquiry Mayo Clinic will be even better able to meet the needs of its patients as it prepares for a new model of health care. We can expect that these endeavors will also help the patients of other health care systems because, as Mayo Clinic leads, it can be expected that others will follow.