The rising importance of family medicine
Dr Margaret Chan
Director-General of the World Health Organization
Excellencies, honourable ministers, family doctors, ladies and gentlemen,
I thank WONCA for organizing this world congress. The work of WHO and WONCA shares much common ground, especially in the priority we give to primary care and prevention.
Given the unique health challenges of the 21st century, this common ground has risen in importance. It is good to see our joint work receiving well-deserved attention.
I thank the Czech Republic for hosting this event in the beautiful city of Prague. We can all enjoy its monuments, its showcase modern architecture, and the many visible signs of its rich history as a centre of trade, culture, and architecture.
I welcome this opportunity to address an audience of family doctors. Your profession also has a rich history, with many achievements to showcase.
Your work continues a long and noble tradition. The first physicians were generalists. Family doctors have always been the backbone of health care. Family doctors have always been the bedrock of comprehensive, compassionate, and people-centred care.
Today, you are the rising stars who offer our best hope of coping with a number of complex and ominous trends. Your talents and skills are needed, and wanted, now more than ever before.
My passion for family medicine is personal as well as professional.
My first career choice was to be a teacher of young children. Then I followed my heart in the most literal sense possible. My future husband had chosen medicine as a career. I adapted my plans accordingly. I followed him to Canada where we undertook our medical studies together.
I have never regretted either of those two decisions. Not the career or the husband.
I have now worked in public health for 35 years. Much has changed, of course. But the rate and complexity of these changes has accelerated most dramatically since the start of this century. These changes have fundamentally altered the landscape of medical care, the nature of threats to health, and the strategies for their prevention.
Ladies and gentlemen,
In our world of radically increased interdependence, health everywhere is being shaped by the same powerful forces, like demographic ageing, rapid urbanization, and the globalization of unhealthy lifestyles.
Under pressure from these forces, the disease burden has shifted in a fundamental way. Chronic noncommunicable diseases have overtaken infectious diseases as the leading cause of morbidity, disability, and mortality.
This shift has major implications for the organization, financing, and delivery of health care.
Prevention has become problematic. The root causes of chronic diseases reside in non-health sectors. They are profoundly shaped by the products and marketing practices of the tobacco, food, beverage, and alcohol industries.
Obesity is also profoundly shaped by some of these industries, and it is likewise on the rise. WHO data show that rates of obesity have nearly doubled since 1980 in every region of the world.
There are many reasons why not one single country has managed to turn its obesity epidemic around in all age groups. Here is just one. Health budgets are ridiculously tiny when compared with the marketing and advertising budgets of these industries.
Populations are ageing at an unprecedented rate. WHO estimates that, within the next five years, the population of people aged 65 and older will outnumber children under the age of five for the first time in history.
The therapeutic arsenal for clinical care has changed, in ominous ways. As drug resistance continues to increase, medicine is losing its front-line antimicrobials at an alarming rate. For some forms of drug-resistant tuberculosis, second-line medicines are failing as well. For some diseases, like gonorrhoea, the cupboard is nearly bare.
Some experts say that medicine is moving back to the pre-antibiotic era. No. With so few replacement drugs in the pipeline, we are moving to a post-antibiotic era where many common infections will once again kill.
This will be the end of modern medicine as we know it. In a post-antibiotic era, sophisticated interventions, like hip replacements, organ transplants, cancer chemotherapy, and care of preterm infants, will become far more difficult or even too dangerous to undertake.
At the same time, new medical technologies, interventions, devices, and drugs for chronic diseases are being developed and introduced with unprecedented speed. They come at a heavy cost.
Medicine is one of the few areas of technical innovation where new products are nearly always much more costly, more sophisticated, more difficult to use, and more likely to malfunction.
This is certainly not the case with other areas of technology, like flat-screen TV’s or computers and hand-held devices, where products keep getting easier to use and cheaper to buy.
In terms of actually being able to afford the latest technical innovations, health care in many countries is approaching the limit, the tipping point where constantly rising costs become unsustainable.
As the Lancet Oncology Commission observed, cancer care in wealthy countries operates in a culture of excess: excessive diagnostic tests, excessive interventions, and excessive promises that create unrealistic expectations for patients and their families.
These expectations, in turn, lead patients to undergo end-of-life interventions that are toxic, painful, disconcerting, and extremely expensive, yet of no proven benefit to patients. As doctors, this was not the kind of service meant when we took the Hippocratic oath.
These trends are universal, and they bring universal challenges to service delivery everywhere. Everywhere, costs are soaring, budgets are shrinking, and public expectations for health care are rising.
And there are other problems. We live in an era of inequalities that are getting worse instead of better. Our world is dangerously out of balance, also in matters of health.
A world that is greatly out of balance is neither stable nor secure. This point was vividly demonstrated in 2011, when protests and demonstrations against social inequalities made the headlines and toppled governments.
Gaps, between and within countries, in income levels, opportunities, health outcomes, and access to care, are greater today than at any time in recent decades.
According to a major study from the Organization for Economic Cooperation and Development, income inequalities have reached their highest level in half a century.
The difference in life expectancy between the richest and poorest countries now exceeds 40 years. Total annual government expenditure on health ranges from as little as US$ 1 per person to more than US$ 7 000.
The rise of costly and demanding chronic diseases is certain to increase these gaps and inequalities even further. In 2010, the USA alone spent US$ 124 billion on cancer care. Worldwide, some 30 countries, including 15 in sub-Saharan Africa, do not possess a single radiation therapy machine.
Against this backdrop, prevention and primary care come to the fore as never before. The ground for this shift has been well-prepared. International public health has learned some major lessons since the late 1970s.
Ladies and gentlemen,
At the international level, approaches to the organization of health services and the provision of care have undergone some recent pendulum swings. The swings have been dramatic, highly visible, hotly debated, and played out on the global stage.
In 1978, the Declaration of Alma launched the health for all movement based on primary health care. It articulated a set of guiding principles and ethical values, including equity, solidarity, and the need for fairness in access to health care. It positioned primary care as the springboard for a larger social and political movement towards more equitable care.
These noble ambitions were followed almost immediately by an oil crisis and a global recession. As resources for health declined, selective approaches using packages of interventions gained favour over the intended aim of fundamentally reshaping health care.
AIDS emerged and exploded. Fuelled by the AIDS epidemic, tuberculosis returned with a vengeance. The malaria situation deteriorated to the point that it was said to be “stable”, since it could hardly get any worse.
The 1980s became known as the “lost decade for development”. The pendulum swung away from broad-based programmes of equitable care towards the urgent management of high-mortality diseases.
At the turn of the century, the Millennium Declaration, with its eight development goals, marked the start of the most ambitious attack on human misery in history, including the misery caused by disease.
Commitment to the health-related goals brought out the best in human creativity and generosity. Innovative ways were found to scale up the delivery of life-saving interventions. Funding increased nearly three-fold.
But commitment to the goals also stimulated the creation of numerous global health initiatives focused on a single disease or set of interventions, such as childhood vaccines. When confronted with weak capacities in recipient countries, many of these initiatives built their own parallel systems for procurement, delivery, financial management, monitoring, and reporting.
The delivery of care became fragmented. Some eye-catching and mind-boggling statistics began to emerge. In a single year, Viet Nam dealt with more than 400 donor missions to review health projects or the health sector. In a single year, Rwanda has to report to various donors on 890 health indicators, with nearly 600 relating to HIV and malaria alone.
With the rise of chronic diseases, the swing is now firmly in the direction of integrated, comprehensive, people-centred primary care. As health professionals now recognize, these diseases cannot be prevented or managed in the absence of a strong primary care infrastructure.
A health system where primary care is the backbone and family doctors are the bedrock delivers the best health outcomes, at the lowest cost, and with the greatest user satisfaction.
One statistic makes the point. In some countries where chronic diseases are the principal health burden, family doctors manage 95% of the health problems while absorbing only 5% of the health budget.
Some would argue that this satisfaction on the part of users extends to health-care providers as well. Some would say that family doctors enjoy the most satisfying and rewarding careers in medicine.
The work of a family doctor is hard and demanding. You don’t earn the highest pay. Your waiting rooms may have patients in every age group, with every imaginable symptom and complaint, with the full spectrum of challenges modern medicine is expected to address.
But you also have the satisfaction of getting to know your patients over time, and watching their lives and health evolve. Family doctors do the detective work that deepens the diagnosis to include the social and environmental causes of ill health.
Studies show that patients want care that is accessible and affordable. Above all, they want care that responds to them as people, in their unique family and social situations. People do not want to be treated like a collection of specialized body parts. They don’t want to have bits and pieces fixed. They want to be treated as people with social and spiritual lives.
In a trend that started in the early years of the AIDS epidemic, many people now seek out their own medical information. They teach themselves how to read and understand research reports.
They search the many web sites that offer medical information. They come for consultations well-informed and ready to question, challenge, and make their own decisions. This can enrich the doctor-patient dialogue, but it also increases demands.
The use of social media can have a dark side, as we know very well from resistance to childhood immunization, out of unfounded fears of an increased risk for autism. This, too, makes the job of preventive care even harder.
Family doctors are the linchpin in the continuum of care. Some of your patients will need specialist treatment in hospitals. You coordinate this part of their care.
Your patients age. They develop multiple co-morbidities that may need treatment by multiple specialists. You remain the guardian of the whole person, making sure that treatments ordered by different doctors do not result in dangerous drug interactions and that contraindications are respected.
Specialized models of medical care are not an ideal approach to the management of ageing populations. Family doctors, who are in the best position to cultivate long-term relationships with patients, are uniquely well-placed to help people age in good health, stay in their homes as long as possible, remain socially engaged, and find the right mix of specialized care when needed.
This integrated approach extends to multidisciplinary teamwork that includes nurses. In fact, one of the reasons why the WHO Surgical Safety Checklist has been so successful is the fact that it engages the whole team, including nurses. All are given shared responsibility and equally important roles in protecting patients from dangerous or deadly errors.
In 2011, the United Nations General Assembly convened a special session on the prevention and control of noncommunicable diseases. This was only the second time in history that a health issue commanded such a high level of political attention.
As the Political Declaration issued by this event clearly stated, prevention must be the cornerstone of the global response to these deadly, demanding, and costly diseases.
Since the start of this century, WHO has made some significant contributions to population-wide prevention through adoption of a number of international instruments. The WHO Framework Convention on Tobacco Control is one especially strong example, as its provisions are legally binding.
Other instruments provide global strategies and policy options for reducing the harmful use of alcohol, and improving diets, nutrition, and physical activity. WHO Member States have also adopted recommendations for reducing the marketing of unhealthy foods and beverages to children.
Yet even if all these strategies were implemented to perfection, we would still have clinical cases of heart disease, cancer, diabetes, and chronic respiratory diseases, and these patients must be managed in growing numbers
Prevention is rightly the cornerstone for the global response. But at the individual level, the personal level, family doctors are the cornerstone for both prevention and care.
Ladies and gentlemen,
Sometimes in technical meetings, when data and statistics are being discussed in the abstract, I have to remind participants to stop for a moment. Go back to the basics. Remember the people.
This is what makes our work matter, whether as family doctors or public health officials.
Health systems are social institutions. They do much more than deliver babies and pills, the way a post office delivers letters. Properly managed and financed, a well-functioning health system contributes to social cohesion and stability. At a time when so many world events give cause for international outrage, social cohesion and stability are prized assets everywhere.
Health systems must have specialists and hospitals, of course. But they must also have primary care doctors who care about prevention. They must have doctors who know their patients long enough and well enough to truly manage the totality of health in all its multiple dimensions, including mental and spiritual needs.
The dignity which every human being has at birth vanishes so easily in the labyrinth of high-tech, specialized, and depersonalized medical care. For patients, being able to talk to a doctor and undergo a professional examination has therapeutic value but also social value as a ritual.
Technology and computers can never substitute for the human side of the doctor-patient relationship. A long-term relationship that instils trust builds motivation. Motivated people are the ones most likely to accept personal responsibility for maintaining good health.
Primary care is our best hope for the future. Family doctors are our rising stars for the future.
Out of the ashes built up by highly specialized, dehumanized, and commercialized medical care, family medicine rises like a phoenix, and takes flight, spreading its comprehensive spectrum of light, with the promise of a rainbow.
This is the ancient historical covenant between doctors and patients, and this is where the health and medical professions need to return. I encourage all of you to continue to cultivate the human side of medicine.