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Exploiting marginality in health: Is ‘subhealth’ another case of disease mongering?

Dr. Benjamin T.Y. Chan

University of Hong Kong, SPACE

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Conceptual issues

‘Medicalization’ and ‘Disease Mongering’ treat the concept of disease as a problem

‘Subhealth’ treats the concept of health as a problem

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What is ‘subhealth’ 亞健康 ?

A condition uniquely known in China that is not classified as a disease, but still requires treatment

A state that exists between health and disease, a so called ‘third state’ forming the continuum between health and disease

A concept whose formation has direct backing from corporate interest and involves the skillful use of media as vehicle for its popularization

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The subhealth condition is characterized by: fatigue lethargy depression slow reaction insomnia agitation poor memory poor concentration social withdrawal and

loneliness prone to illnessand many more……

panic dizziness headache indigestion shortness of breath sweating aching and pain in the

waist and legs poor social relationship feeling sick

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Subhealth is associated with the high tempo of life in a modern society. Its causes are multifaceted:

Social, psychological, environmental, genetic, and unhealthy lifestyles, habits and behaviors

Subhealth is related to occupational stress and mental fatigue.

Teachers, students, medical workers, engineers and technicians

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Reported Prevalence of ‘subhealth’

Subhealth epidemiological survey in ‘China Youth Daily’ covering 51,303 respondents nationwide revealed that:

20.87% are healthy;58.18% are in a subhealth state;5.62% are diseased;13.38% are unsure about their state of health

China Health Care Association survey of 16 cities with population greater than 1 million revealed that:

75.31%, 73.49% and 73.41% of residents in Beijing, Shanghai and Guangzhou respectively are in a subhealth state

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Subhealth is believed to be most prevalent among while collar workers and intellectuals with high education level. Survey by the Chinese Academy of Sciences indicates the average life of Chinese intellectuals to be 10 years lower than the national average

Media participates in fanning scare about consequences of untreated subhealth leading to chronic diseases, sudden and early death

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Problematization of ‘health’

WHO defines health as:“a state of complete physical, mental and social

well-being and not merely the absence of disease or infirmity”

This definition does not provide a conceptual scheme in which to evaluate the complete spectrum between health and illness that includes the three dimensions

American medical sociologist, F.D. Wolinsky, has attempted to address this problem by constructing a three dimensional typology

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Three-dimensional representation of health

Source: p.95 FD Wolinsky (1988) The Sociology of Health, 2nd ed. p.95

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Eight health states in the three dimensional modelHealthState

1

2

3

4

5

6

7

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Label

Normally well

Pessimistic

Socially ill

Hypochondriacal

Physically ill

Martyr

Optimistic

Seriously ill

Psychological dimension

well

ill

well

ill

well

ill

well

ill

Physical dimension

well

well

well

well

ill

ill

ill

ill

Social dimension

well

well

ill

ill

well

well

ill

ill

Percentage*

48.3

11.0

2.2

3.9

11.5

7.6

2.2

13.2

*Based on a example of 500 North Carolinians

Source: FD Wolinsky (1988) The Sociology of Health, 2nd ed. p.97-98

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The three-dimensional model does not provide the answer to the definitional problem of health. Issues to be tackled as identified by Wolinsky include:

Evaluation of each health state identified

Evaluation of the relationships among these health states

Delineating process of transition from one health state to another

Examining weighting factor for each dimension in contributing to a composite health status

Describing process of interaction between the three dimensions

Delineating relationship of health states to the larger social system

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Chinese health researchers’ response to the problem of defining health is to propose a ‘dynamic transformational model’:

Health Subhealth Disease

Instead of

Health Disease

+ 0 (floating)

The representation of health, subhealth and disease is

A B

+ C D

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The representation of health, subhealth and disease is

A B

+ C D where:+ C = Health D - = DiseaseA B = SubhealthAC = Overlap between health & subhealthDB = Overlap between subhealth & disease

In this representation, a line spectrum A B replaces 0 and subhealth therefore acquires limits. There can be moderate (AC) and severe (DB) grades of subhealth, the latter representating a pre-clinical state

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The significance of the ‘dynamic transformational model’ is to provide appropriate bases for looking after these various states, where:

State

Health

Subhealth

Disease

Action required

Nourishment

Modulation

Therapy

Modality

Exercise, nutrition

Chinese medicine, Rehabilitation medicine, Health food

Western medicine

States of overlap between health and subhealth and between subhealth and disease would require combination of actions and modalities

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Why ‘subhealth’ fits within the same problem framework of ‘medicalization’ and ‘disease mongering’? Subhealth has effectively acquired a quasi-

disease label Subhealth is defined mainly by corporate-

influenced agenda rather than genuine public health concerns

Subhealth has aroused national interest through widespread media coverage

Subhealth gives rise to a number of products and services that aim to ameliorate or provide recuperation for this condition

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To understand subhealth and its influence on the Chinese health scene, a three-part analysis is given: Construction of subhealth as a condition Construction of diagnosis and treatment

for subhealth Construction of channels of propagation

and further research

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Construction of subhealth as a conditionPre-initiation stage (From mid-1980s) Soviet influenced rehabilitation medicine was

popularized in China. The concept of ‘grey state’ or ‘third state’ developed by N. Behrman was introduced into China and the first scientific paper on this subject was published in 1990

Initiation stage (1996-2002) Chinese physician Professor Wang Yu Xue ( 王育學 )

first proposed the concept of subhealth in tandem with the marketing of a new Chinese medicine and health food brand-named ‘Cai Li’ 采力 and manufactured by Haier 海爾 Pharmaceutical Company

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Haier supported the first ‘Academic Seminar on Subhealth’ held in Beijing in May 1997 under the auspices of the Chinese Pharmaceutical Association (Geriatric Medicine specialist group)

In July 1997, during the ‘Seminar on Strategy for Launching Chinese Health Food into the World Market’ convened by the Ministry of Health, it was proposed that the target market for health foods should be people who are in a subhealth state

2nd Academic Seminar on Subhealth held in April 1998 put forth recommendation to conduct a nationwide epidemiological survey on subhealth in association with ‘China Youth Daily’

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•3rd Academic Seminar on Subhealth held in August 2001 at Haier Pharmaceutical Company’s headquarter in Tsingtao endorsed the ‘dynamic transformational model’ and supported publication of a ‘Subhealth book series’

Subhealth: a new concept of health in the 21st century by Wang Yu Xue (2002). Jiang Xi Science and Technology Press

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Post-initiation stage (2002-present) ‘China Academic Seminar on Subhealth’ is now

an annual event sponsored by various academic societies under the supervision of the Ministry of Health and the State Food and Drug Administration. Smaller scale seminars and workshops are held in various provinces.

‘World Academic Conference on Subhealth’ was held in January 2006 under the auspices of the World Federation of Chinese Medicine Societies and co-sponsored by the State Administration of Traditional Chinese Medicine

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Construction of diagnosis and treatment for subhealth Subhealth condition being distinct from

disease state requires diagnostic methods that are different from clinical chemistry and conventional medical imaging technology

Subhealth treatment draws from the modalities of Chinese medicine, rehabilitation medicine and health food

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Examples of diagnostic methods

1. Health evaluation MDI (ICD-10)

85-100 health; 70-85 subhealth; <70 disease Delphi method derived diagnostic criteria made up of 18

symptoms divided into 6 groupings SCL-90 (Symptom Checklist-90) CMI (Cornell Medical Index) + SCL-90 + EMBU (Egna

Minnen Betraffande Uppfostran)*

*EMBU assesses adults’ memories of parents’ rearing practices

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2. Microscopy Diagnostic Instrument (MDI) Most commonly used version is the Tsinghua

Multimedia Computing interface This technology originated by Stanford scientist

R Bradford uses CMOS sensors to achieve ultra-high power magnification (up to 20,000x) and high definition image capture

Live blood cells can be observed and a spectrum of blood cell profile is used to explain derangement in organ functions

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MDI is commonly referred to as “A drop of blood test”

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3. Thermal Texture Maps (TTM) A non-invasive imaging technology that can

provide functional (as against anatomical) information of living cells

The thermal-infrared imaging slicing technology is developed by Chinese scientist Liu Zhong Qi (Beijing Industry University) and patented in the US

It detects heat generated by metabolic activities of living cells and is capable of discriminating healthy and diseased tissues

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TTM is commonly referred to as “Hot CT”

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Examples of treatment

1. Chinese medicine and health food

‘Cai Li’ 采力 is the original product launched by Haier to popularize the concept of subhealth. It is based on a classical herbal formula in Chinese medicine and is being marketed in both medicine and health food forms that are approved by medicine and food regulatory authority in China.

Chinese medicine form Health food form

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2. Subhealth treatment is available in specialized medical centers. Salient examples are given below:

Dong Hua 東華 Hospital (Local TCM hospital in Beijing operated by the Red Cross Society of Chinese and Ministry of Health) has established a specialized outpatient clinic for subhealth. It pioneered the use of stellate ganglion block

Beijing Kang Ya 康亞 Hospital is a private hospital and the first one to be dedicated entirely to the diagnosis of subhealth condition

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Tianjin First Center 天津第一中心 Hospital is the first one to establish a Subhealth Rehabilitation Center in 2000. It offers both diagnosis and treatment for subhealth

Countless other units exist around the country and they are all characterized by their aggressive marketing strategies and profit orientation

Complementary therapies and conventional physiotherapy are also used in the treatment of subhealth. Some forms used by Tianjin First Center Hospital include music therapy, static electricity therapy and float therapy

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High voltage static electricity therapy

Music therapy Float therapy

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Construction of channels for propagation and further research

Subhealth is a topic of recurrent interest in the popular health media in China

Subhealth dedicated websites (virtually all of them are commercially sponsored) are impossible to count

The most important and well-known portal for subhealth information is at http://www.subhealth.com

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• There are evidences to suggest that the subhealth concept is starting to spread outside of China. Examples include the following:

US Chinese medicine commercial website

Hong Kong Health Journal March 2005 (paid advertisement)

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• Research on subhealth has been steadily increasing since 1996 and the number of publications indexed in the China Journal Net database reflects this trend

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41.18%

21.85%

15.97%

6.72%

2.52%1.68%4.20%

5.88% Theory

Therapy

Epidemiology

Dignostic methods

Clinical presentation

Etiology

Review

others

•According to the bibliometric study of Liu et al. (2004)*, the breakdown of themes in subhealth research articles are

26.89% of the total belong to TCM research

*Chin. J. Mod. Med. (2004) 14(17):155-156

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•The majority of research papers are published in lower-tiered journals with a few excellent ones appearing in The Chinese Journal of Epidemiology

•There is clear reluctance among mainstream medicine and health researchers to accept and use the concept of subhealth. For example, noted cardiologist and health educator, Prof. Hong Zhao Guang 洪昭光 has attended subhealth academic seminar but never used the concept in his own magazine ‘Medicine & People” 藥物與人•The research field is dominated by TCM researchers and epidemiologists with an interest in occupational health matters. The Chinese Association of Chinese Medicine has in conjunction with the State Administration of TCM issued a set of “Provisional Guiding Principles for Clinical Practice Research in Sub-Health” in December 2005

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Observations

Subhealth is a unique form of socio-cultural construction of health and illness in a society that is experiencing rapid epidemiological transition to chronic disease burden especially among the urban population

Subhealth construction is facilitated by the interplay between official health agencies, semi-official academic societies and various business interest groups aided by the power of the media

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•Subhealth offers non-orthodox modalities a chance to secure their niche in the fee-paying health market

•Subhealth is often confused with Chronic fatigue syndrome (CFS) although the prevalence rate of the latter is found to be very low in the population. Possible overlaps between subhealth and Medically Unexplained Physical Symptoms and other somatoform disorders/ subthreshold psychiatric morbidities may be possible but these await investigation

•Grades of subhealth and their determination lack refinement. Classification as to whether the subhealth condition is minor psycho-physical imbalance sub-clinical or pre-clinical would be useful from both preventive medicine and clinical points of view.

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Recommendations

•To refine the determination and specify diagnostic criteria for grades of subhealth, the various psychometric measurements used should be improved. One good starting point is the diagnostic criteria developed by researchers in the Epidemiology Department of Jinan University Medical College in Guangzhou

The diagnostic criteria are arrived at through 2 rounds of expert consultation based on Delphi method

There are 18 symptoms divided into 6 groupings (physical, psychological, vigor, social adaptability, immunity, medical consultation)

Each of the symptom groupings has 4 levels of response

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In its current usage, ‘Minor subhealth’ would be reflected by indicators from the physical and psychological groupings; ‘Sub-health’ would be reflected by indicators from vigor, social adaptability and immunity groupings; ‘Pre-clinical state’ would be reflected by indicators from medical consultation grouping

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•To re-orient subhealth concern from profit motive to the safeguard of public health, a focus on chronic disease prevention is necessary.

•China is facing by an ageing population (10.5% of population aged 60+ in 2003) and will need to confront the ageing problem and attendant health care expenditure cost before it shakes off its developing country status.

•Epidemiological survey of occupational stress and mental fatigue should be geared towards finding true levels of risk. Research on the health state of Chinese intellectuals carried out by the Chinese Renmin University Population and Development Center has found no difference between life expectancy and life stress levels of university professors when compared to common citizens in the control group.

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Impact of chronic disease in ChinaFacts:

•In China, chronic diseases are projected to account for 79% of all deaths.

WHO projects that over the next 10 years in China:

•Over 80 million people will die from a chronic disease.

•Deaths from infectious diseases, maternal and perinatal conditions, and nutritional deficiencies combined will increase by 2%.

•Deaths from chronic diseases will increase by 19% - most markedly, deaths from diabetes will increase by 50%.

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33%

20%17%

1%

8%

10%

11%Cardiovascular disease

Cancer

Chronic respiratory disease

Diabetes

Other chronic diseases

Communicable, maternal andperinatal, nutritionaldeficienciesInjuries

Projected deaths by cause, all ages, China, 2005

Source: WHO, http://www.who.int/chp/chronic-disease_report/en/

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Conclusion

•Subhealth can be a force for good in furthering understanding of health and in achieving a definition of health based on empirical constructs.

•However, the rigor of research should be strengthened and separated from political and economic interests to reclaim its scientific merit.

•This case study of subhealth suggests that it is possible to achieve ‘disease mongering’ by working from either end of the health and disease spectrum