“Principles of Holistic Primary Health Care” 

Preamble:
The Following declaration expands upon the Alma Ata Declaration where the principles of Primary Health Care (PHC) were first defined[i]. The conference was attended by 3000 delegates from 134 governments and 67 international organizations from all over the world. Despite its noble goals and almost universal global endorsement, international policy has since generally embraced the approach of “Selective” Primary Health Care as defined by Julia Walsh and Kenneth Warren as an “interim” strategy[ii]. Following a 29 year “interim” the global community appears no closer to realizing Alma Ata’s goal of ‘Health for all’ or even enacting the principles of PHC. The following declaration is thus issued as an international call to alms, by embracing the spirit of the original Declaration and expanding it to encompass the global community’s needs for the twenty first century.

This declaration urges governments, WHO, UNICEF, and other international organizations, as well as non-governmental organizations, funding agencies, health care workers and the global community as a whole to support Holistic Primary Health Care and to channel increased technical and financial support to it. By ratifying The declaration you affirm the principles of Holistic Primary Health Care and agree to introduce changes in the existing health delivery system in which you participate so that it properly supports HPHC as the overriding health priority.

 

The Principles of Holistic Primary Health Care

1# Hippocratic – “Primum non nocere”

“To first do no harm”, is the foundation stone of HPHC and all work that seeks to return and maintain health in its broadest sense. The highest ideal of health care is therefore stated to be the gentle and permanent restoration of health, in the most harmless way possible, together with its ongoing and sustained safeguarding for future generations. Non-violence and respect in response to the fragility and sanctity of all life is seen as the guiding principle against which all health care interventions and initiatives must be carefully weighed. With conservative estimates suggesting that at almost 800 000 iatrogenic US deaths each year[i], medical error is now the single greatest cause of death in America a critical re-evaluation of the foundations of medical practice is obviously needed. Due to the popular misconception that this principle is currently, or has ever been in the Hippocratic Oath, it has been elevated to the founding principle of HPHC to protect against avoidable iatrogenic morbidity and mortality.

2# Rights Based – “Health as a right of life”

The health of all life, and that of the global ecology as a whole is here asserted as an inalienable “Right-of-Life”. Every living being is born with the right to life, and is similarly endowed with the right to health. Human beings should therefore act towards one another, their environment, and all of life in a spirit of care and non-violence. The ideal of human beings enjoying freedom from fear and want can only be achieved if conditions are created that restore, sustain and protect health in its broadest sense. The purpose of Health Care therefore, cannot be economic growth, for it is an end unto itself, and cannot be undertaken in the spirit of a ‘FOR-profit’ endeavor. As disregard for health on a global scale has resulted in damaging acts to both ourselves and our broader ecology, the advent of a world in which all human beings may live in health and harmony with their environment is here proclaimed as an overriding global priority. A rights based approach to health care also strongly emphasizes the importance of equality of access, and insures that those with greatest need are able to participate in quality health care programs. In addition to this, the objectively informed patient should have the due opportunity for a truly informed choice, and should have the right and opportunity to reject or accept any treatment, and/or seek and be informed of viable alternatives.

3# Community Orientated – “Health is of the people”

Since health is ‘of the people’ it is of paramount importance that provisions for its care are directed, implemented and overseen in close consultation with the community at large. The excessive expropriation of health from the public, community and family domains by the medical community is here seen as ultimately a counter productive and ‘un-healthful’ approach. HPHC is hereby affirmed as a community based model intended to be implemented by those whom it pertains to directly. Health care workers are therefore entrusted with the task of education and dissemination of knowledge to ensure individual and community empowerment. This is to be undertaken in a spirit of co-operation and exchange, with local medicine, knowledge and tradition to be given a high priority whenever appropriate. Individuals and community groups are consequently vested with the responsibility, education and power to actively participate in the governance of their health care. In this light, health is also to be considered as a vehicle for social change and harmony. Important regulatory checks and measures are therefore insured by the return of decision making and directive power to the greater community. As health is created, sustained or destroyed within the settings of everyday life, the reorienting of healthcare needs to move beyond its current limited focus of providing clinical and curative strategies that address disease and embrace the broader principles of HPHC as they apply to the community’s everyday life practices. This in turn necessitates the adaptation of treatment approach to the community which it takes place within, and the individuation of approach where ever possible.

4# Health Focused Model – “Positive, promotive and preventative”

The primary focus and orientation of health care should be directed towards actively restoring, sustaining and protecting health; this is in contrast to a disease focused model which wages war upon the perceived enemies of health. Health, as a dynamic state of individual and collective equilibrium is reaffirmed as more than simply the absence of the signs and symptoms of disease, and must therefore be positively engaged. A preference for strategies that actively promote a state of health and sustained healthful ways of being must therefore be used to guide all initiatives and interventions[ii]. In turn, prevention of the arising of dis-ease in its broadest sense, is thus seen as an equal imperative for all individual and collective health care programs, with appropriate educational, nutritional, socio-economic and ecological measures accompanying the majority of treatment protocols. With US health care costs totaling 1.6 trillion in 2002 at 14% of the nation’s GNP it is clear that there is also an economic imperative to amend the disease focused strategies of Selective Primary Health Care models.

5# Socio-ecological Context – “The health of the whole”

HPHC affirms the link between health and the total environment in which it is either sustained or destroyed. Ecologically informed public health strategies are necessary to address many of the root causes of dis-ease in the twenty first century. Systemic assessment of the impacts upon human health by the changes in our environment brought about by technology, economics, urbanization and energy production has long been recognized as essential for public health.[iii] The broader global ecology and its homeostasis are therefore of critical importance when considering individual and local manifestations of health or its absence. Selective interventions which do not address imbalances at the socio-ecological level are at best temporary, and at worst dangerous co-contributors to the problem. Whilst the environmental and sanitary causes of previous epidemics have been historically identified and remedied, the equivalent solutions are unlikely to be forth-coming for the modern epidemics from which we suffer, unless the narrow lens through which we view them is broadened to include the health of our greater ecology. An environment of economic destitution is indeed one of the critical social determinants of health, but as history has taught us, it often requires more than economic interventions alone. The health of the whole system that the diseased part participates in is consequently of paramount importance when considering all health care initiatives.[iv]

6# Multi-sectorial and Inter-disciplinary - “The Co-operative Approach”

Due to the holistic nature of health and its diverse primary determinants[v], HPHC entails a movement towards a more integrative and co-operative approach. As stated in the definition of care below, within a holistic model of health care there can be no “orthodoxy” and “alternative”, rather there is simply care that is efficacious, appropriate and safe. This necessitates a greater level of collaboration between the various sectors and specialists that have arisen from a diverse range of cultures and traditions. A multi-sectorial approach entails an even wider level of collaboration as health care is undertaken in co-operation with the expertise of non-medical personnel and organisations. Indeed, if health as it is defined, is to be restored and sustained, then it can only be done with the full participation of every member of the global community, for as elaborated below, health cannot be ensured by the health care sector alone.

7# Minimal Intervention - “Maximum Sustainability”

HPHC embraces the principle of seeking the smallest, least invasive and gentlest intervention possible to effectively restore health. This is not to justify laxity or lasse fair health policies, but rather is included to address the often dangerous effects of ‘heroic medicine’. With 164 million estimated unnecessary medical interventions taking place in the US alone over a ten year period, and an accompanying 32 million iatrogenic incidents[vi] it is clear that the current approach is not only unsustainable, but also dangerous. As a guiding principle, minimal intervention is intended to cultivate an awareness of the delicate balance of all naturally occurring systems, including human health. In this context, a very small intervention can give rise to a large range of effects and reactions, not all of which could have possibly been foreseen, or are in themselves desirable. To ensure the protection of such individual and collective equilibriums against well intentioned but overzealous interventions, HPHC explicitly errs on the side of caution. Such a concept is inextricably linked to the desire for maximum sustainability, as large scale interventions are rarely viable over the long term. As a whole this principle also necessitates the management of health, as it is by nature more economically managed than is disease.

8# Decreasing Dependency – “Supporting people to support themselves”

Decreasing dependency within health care should be at once, a principle, a goal and an outcome of all effective initiatives that seek the permanent restoration of health. This should generally be accompanied by an overall reduction in cost, with escalating health costs signaling a failure to return and sustain homeostasis, either collectively or individually. Whilst this may not always be practically possible, it is none the less one of the philosophical foundations of HPHC. In conjunction with the community oriented focus previously outlined, decreasing dependency also contributes to the important checks and measures contained within HPHC to insure both efficacy and adequacy of care. The goal of self sufficiency is closely aligned to that of health, and must always be borne in mind. A long term perspective must be maintained to insure that the many outcomes and effects of any intervention are inevitably leading to a sustained state of health that enables enhanced levels of independence and freedom. Communities and individuals alike are therefore not only encouraged to participate in the decision making process of their health care, but as far as possible to be actively engaged in its implementation.

9# Nutritional and Lifestyle Considerations – “Prevention is better than cure”

Given the almost universal acceptance of nutritional and lifestyle considerations in the role of disease, HPHC seeks to emphasize such primary determinants in all health care initiatives.[vii] Included under the umbrella of Lifestyle considerations must be their societal equivalents of public hygiene and sanitation, and their respective demands for water and air that is free from contamination and disease causation. Great care must therefore be made to avoid medical intervention and palliative measures when the causes of dis-ease lay squarely in defective nutrition and poor lifestyle choices. Failure to do so will only further entrench the condition further, both within the individual and the community at large, resulting in replacement morbidity and mortality whilst adding broad reaching collateral costs that are difficult to repair[viii]. The advances in public hygiene and nutrition that were responsible for the decrease in most of the infectious diseases of the nineteenth century in Europe must not be forgotten when considering the primary determinants of health. Indeed, in accordance with the principle of Minimal Intervention, such considerations should be routinely assessed before any medical treatment, holistic or otherwise, is even proposed. Provisions must therefore be made to understand and prevent the many ailments that are easily averted through such non-invasive, cost effective and universally benign measures if the enigma of world health is to be attained.

10# Educational Imperative – “Knowledge as power, as health”

Holistic and long term strategies must entail a strong educational component if the concentration of knowledge, skills and power that has resulted in the western vertical hospital based system is to be expanded to meet the crisis facing the global community in the twenty first century. The re-appropriation of health by the community at large requires a dissemination of power in the form of basic health care education. It is in this light that HPHC asserts the absolute necessity of an educational component to all health care initiatives. Indeed, a broad based, horizontally implemented, community oriented, decreasingly dependent, health focused and nutritionally informed system of health care cannot by definition exist without such an educational imperative. Furthermore, if the ‘duty of care’ that HPHC entails is formally adopted then this educational imperative is consequently expanded to address the broader global community, and not simply those whom we are seeking to directly assist.

Definition of Holistic

The Holistic approach is one based upon the idea that all the properties of a given system (biological, social, economic or ecological) cannot be determined, reduced, or explained by the sum total of its parts. Health when not conceptualized in this manner as an indivisible whole, is distorted, destroyed or lost as it is reduced to a collection of ‘selective’ parts or markers. A Holistic approach should thus act as an important regulative measure in politics and medicine alike, to guard against narrow and limited perspectives that are harmful in their practical consequences and long term results. When an interdependence of relationships in world health is emphasized, along with the conceptual web that joins those relationships, the emphasis shifts to the constant dynamic processes that maintain our greater human ecology, and a more effective and sustainable approach may be maintained.

A holistic perspective views all phenomena, but most particularly living systems, as interconnected or interdependent systems within a broader system or whole.

Definition of Primary

Health Care that is of a ‘Primary’ nature is that which is essential to achieve a state of ‘health’ as defined below. This may be further defined in relation to the proposed determinants of health. As suggested by the LaLonde Report, [i] there are at least four primary determinants of health including (but not limited to) healthcare services and medical intervention; also included are human biology, lifestyle and the environment at large. Thus, health is primarily maintained and improved not only through the advancement and application of medicine, but also through the efforts and intelligent lifestyle choices of the individual as promoted and supported by the community at large. Adequate provisions for and emphasis on lifestyle services, education and care are therefore of paramount and primary importance. Similarly, the greater ecology is equally of primary significance in determining both the individual and collective state of health. Environmental and ecological considerations, models and consequences are also highlighted by this declaration as being of a primary nature and of the upmost importance. Holistic “Primary” Health Care must therefore de-emphasize the singular role of orthodox healthcare services and medical intervention in order to include a broader range of health determinants. In this light, the current multiplicity of Health Care providers, hospitals and selective interventions cannot be a priori viewed as a positive reflection on world health, but rather, may be a testament to our failure to address the broader primary determinants of health.

Definition of health

This Declaration reaffirms that health is not merely the absence of disease or infirmity[ii], nor is it simply the absence of the symptoms there of, but rather it is a dynamic state of complete physical, mental, emotional and social well-being, which in turn creates the ability to sustain a socially, economically and ecologically productive and harmonious life. Health, is thus seen to be a dynamic state of individual and collective equilibrium that exists within ones internal ecology and is both inseparable and dependent upon the greater ecology as a whole. Furthermore, it is upheld as a fundamental human and global right, and a responsibility that is shared by all. The attainment of the highest possible level of health and healing is therefore seen as a critical world-wide goal whose realization has implications for the global ecological equilibrium as a whole. The promotion and protection of the health of humanity, as defined above, is therefore declared essential to sustained global homeostasis itself.[iii]

Definition of Care

As a fundamental Human Right, health is here seen to invoke the common law requirement of a “duty of care”. This means that it is a requirement that all people, nations, communities and companies act toward others and their environment with the watchfulness and respect that is necessary to ensure the protection and continuation of the collective state of health. Health “Care” is not to be seen solely as the obligation and responsibility of health care professions, but rather, it is a right and responsibility that is shared by all, and must therefore also be included in the agenda of policy makers in every sector of society. Neither can there continue to be an ‘orthodox’ and an ‘alternative’ or ‘complimentary’ care, for in so doing we simply divide our efforts that are in the end directed towards a common goal. In considering the parameters of such care it is important to recall the wide definition of health, and the acknowledged determinants of health that embrace our broader ecology. Thus, in caring for the health of our neighbour, it is necessary to extend our care to that of the broader community of which they are a part, and ultimately the living web of relationships that sustains us all. Thus the concept of reciprocal health maintenance must be embraced. All sectors should therefore cooperate in a spirit of partnership and service to ensure health for all, as the attainment of health by one part of the globe directly concerns, benefits and depends upon the attainment of the health of the whole.

 

[1] “Declaration of Alma Ata: International Conference on Primary Health Care, Alma Ata, USSR, 6–12 September 1978,”

http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf

[2] J. Walsh and K. Warren, "Selective Primary Health Care: An Interim Strategy for Disease Control in Developing Countries," New England Journal of Medicine 301, no. 18 (1979): 967–974.

[3]Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA . 1998 Apr 15;279(15):1200-5.

Death by Medicine, Gary Null, Ph.D., PhD; Carolyn Dean MD, ND; Martin Feldman, MD; Debora Rasio, MD; and Dorothy Smith, PhD: http://www.whale.to/a/null9.html

[4] Ottawa Charter for Health Promotion First International Conference on Health Promotion

Ottawa, 21 November 1986 - WHO/HPR/HEP/95.1

[5] Ottawa Charter for Health Promotion First International Conference on Health Promotion Ottawa, 21 November 1986 - WHO/HPR/HEP/95.1

[6] HPHC thus shifts the existing focus of socio-economic based interventions to a broader socio-ecological context, whilst maintaining the requirement for economic equality. Health is not only economically sustained however, because by definition it is not only an economic phenomenon. It is in the context of this declaration a collective phenomenon that is either sustained or destroyed by our broader human and global ecologies. Health strategies that target the economic causes of dis-ease alone are by definition limited, narrow and of questionable value. Whilst it may seem that advances in health are due primarily to economic development itself rather than any particular advances in medical knowledge, experience and international history does not support this idea. Economic prosperity alone does not safeguard this most basic goal of humanity.

[7] Lalonde, Marc. "A New Perspective on the Health of Canadians." Ottawa: Minister of Supply and Services; 1974

[8] Death by Medicine, Gary Null, Ph.D., PhD; Carolyn Dean MD, ND; Martin Feldman, MD; Debora Rasio, MD; and Dorothy Smith, PhD: http://www.whale.to/a/null9.html

For calculations detail, see “Unnecessary Hospitalization.” Sources: HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville , MD. Available at: http://www.ahrq.gov/data/hcup/hcupnet.htm . Accessed December 18, 2003 . Siu AL, Sonnenberg FA, Manning WG, et al. Inappropriate use of hospitals in a randomized trial of health insurance plans. N Engl J Med . 1986 Nov 13;315(70):1259-66. Siu AL, Manning WG, Benjamin B. Patient, provider and hospital characteristics associated with inappropriate hospitalization. Am J Public Health . 1990 Oct;80(10):1253-6. Eriksen BO, Kristiansen IS, Nord E, et al. The cost of inappropriate admissions: a study of health benefits and resource utilization in a department of internal medicine. J Intern Med . 1999 Oct;246(4):379-87.

[9] “The most likely factors leading to health improvements are a rise in the levels of nutrition and the slow spread of modern ideas of personal hygiene. In other words, the principal factor behind the improvement in health . . . in Developing countries is probably not any form of health measure, but economic development itself. . . . Mere exposure to a disease agent need not produce clinical disease and very frequently does not do so. Malnutrition is of such significance essentially because it hampers the body's resistance. Malnutrition acts "synergistically" with disease agents to increase the incidence of clinical disease and aggravate its severity.“

Sharpston, M.J., "Health and the Human Environment," in Health, Food and Nutrition in Third World Development, Ghosh, PK. editor, prepared under the auspices of the Center for International Development, University of Maryland, and the World Academy of Development and Cooperation, Washington, DC, International Development Resource Book No. 6, Greenword Press, a division of Congressional Information Service Inc., Westport, Conn. USA, 1984, pp. 85 and 80

[10] For obvious reasons, the highest priority must be given to preventive measures. If good nutritional status is maintained in the first years of life, successive attacks of most infectious diseases of moderate virulence will probably produce no more than mild effects.

Standard, K.L., "Infections and Malnutrition--Child Mortality," in Epdemiology and Community Health in Warm Climate Countries, Cruickshank, R., et al, editors, Churchill Livingstone, Edinburgh, UK, 1976, pp. 45-48

[11] Lalonde, Marc. "A New Perspective on the Health of Canadians." Ottawa: Minister of Supply and Services; 1974

The LaLonde report is a 1974 report produced in Canada entitled A new perspective on the health of Canadians. It is considered the first report acknowledged by a major industrialized nation to state that health is determined by more than just biological factors. As a result of this, it proposed a so-called field of health. This health field represented health as being dependent upon four related aspects - biology, environment, lifestyle and access to healthcare services.

The fundamental conditions and resources for health according to the Ottawa Health Charter by comparison are:

_ peace,

_ shelter,

_ education,

_ food,

_ income,

_ a stable eco-system,

_ sustainable resources,

_ social justice, and equity.

Ottawa Charter for Health Promotion First International Conference on Health Promotion

Ottawa, 21 November 1986 - WHO/HPR/HEP/95.1

[12] See WHO, Constitution of the World Health Organization, as adopted by the International Health Conference, New York, 19–22 June 1946;

“Health is a state of complete physical, mental and social well-being and

not merely the absence of disease or infirmity.”

http://www.who.int/governance/eb/who_constitution_en.pdf

[13] “Holism and ecology are essential issues in developing strategies for health promotion”

Ottawa Charter for Health Promotion First International Conference on Health Promotion

Ottawa, 21 November 1986 - WHO/HPR/HEP/95.

back to main page