Thursday, November 05, 2009

Summary of the Canadian Health Care System

Canada is ranked as the second largest country in size but 39th in population (CIA, 2009). These two factors combine to make it quite unique. The Canadian health system is just as unique. Bordering the United States, which has the antithesis of a single payer health system, Canada has maintained one of the most successful health systems in the world for the past 40 years.

With more than 80% of the population living in urban areas, the health system can make primary and acute care accessible to a large population (CIA, 2008)(WHO, 1996). Life expectancy is among the highest in the world for both men and women at 79.6 (StatCan, 2001). The infant mortality rate (IMR) for 2005 was 5.4 per 1000 births, making it one of the lowest in the world (StatCan, 2005). Since life expectancy is so high and IMR is so low, 12% of the population is over the age of 65, a high percentage of older population. Added to the fact that fewer people are having children, this means that Canada is in the fourth stage of a demographic transition.

The Canadian health system has some of the best health outcomes in the world, with death and disease rates lower than most. Still, only 52% of Canadians say they are satisfied (Gallup, 2003). One of the major complaints is long wait times for special services such as MRIs and other high demand treatments.

In 1957, the Hospital Insurance and Diagnostic Services Act (HIDS Act) was passed, establishing single payer insurance that implemented universal coverage for inpatient hospital care. The HIDS Act set into motion a foundation on which the Canadian health system as we know it was built. It evolved into the national health system, which provides universal coverage to 10 geographically and culturally diverse provinces (WHO, 1996).

Funding and Spending

Many people call the Canadian system “socialized medicine” but actually it more closely resembles a Medicare system where the heath insurance is government sponsored. This means that physicians are not hired by the state but are privately employed and are paid fee-for-service by the government using taxpayer dollars (Davis, 1999). In 2006, Canada spent $3,672 per capita, and health costs were 10.0% of Gross Domestic Product (GDP). Seventy percent of total health costs are publically funded (WHO, 2006); thirty percent comes either from private insurance, employer insurance, or out-of-pocket (Davis, 1999).


The Canadian health care system has two main levels of power. The first is the provincial, in which the health ministries take on the day-to-day management of health services. The ministers of health plan, finance, and evaluate all types of care, e.g. hospital, physician, and public health. Provincial health ministries must also fund all public health activities and negotiate fees (WHO, 1996).

The second level of power is at the federal level. The federal government's role is to set and administer national standards for the health care system. Another federal responsibility is providing health care delivery to veterans, native Canadians living on reserves, military personnel, federal prisoners, and the police. The final function is disease surveillance, prevention, and health promotion (WHO, 1996).

Primary Health Care and Public Health

The lion’s share of primary health care is delivered by a general practitioner or a family doctor. Since they are the first point of contact in the health system they filter access to specialists, admission to hospitals, and other health professionals (WHO, 1996).

The original intent of public health was to control and prevent communicable disease. Since communicable diseases have mostly been ameliorated in Canada, public health has extended its mission to include health promotion and equitable distribution of health services to all members of society, as well as prevention of non-communicable disease and support for mental health services (WHO, 1996).

The Role of the Private Sector

Besides a single payer health system, there also exists a private sector. Canadians might opt to go to the private sector because of dissatisfaction with the public system or to seek an alternative and complementary treatment. The government is not responsible for payment of claims for those who elect to choose that option. There are many doctors, chiropractors, dentists, and such who operate outside of the government provided system. In addition, there are private insurance companies that can supply employers with supplementary health insurance (WHO,1996).


One admirable aspect of the Canadian health system is that it doesn’t rest on its laurels. Building on its foundation of universal coverage, Canada strove even further to insure all of its people. Using the public health system to focus on health promotion and health equity, Canada has achieved some of the best health outcomes in the world. Today’s topsy-turvy economy raises many concerns regarding sustainability. Even in that arena, Canada has created many ways of cost containment, thus promising a continued healthy future for its healthcare system.


CIA , World FactBook. (2009). Canada: people.
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Davis, J B.. (2001). Canada’s health system. Croatian Medical Journal 40(2).
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Gallup. (2009). Healthcare System Ratings: U.S., Great Britain, Canada.
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Statistics Canada. (2001). Life expenctancy.
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Statistics Canada. (2005). Infant mortality.
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World Health Organization (1996). Health Care Systems in Transition: Canada.
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World Health Organization (2006). Canada: statistics.
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Tuesday, September 01, 2009

The True Power in Tai Chi

Recently one of my martial arts friends asked me to work out, and I had to decline because of the broken scaphoid bone in my wrist—an old injury—and two other recent injuries. My knee most probably has a tear in a tendon from walking on the broken sidewalks in India with 100 lbs of luggage this summer, and my shoulder tendon has been burning every time I reach for something. Alas, the sounds of a wimp! But, hey, that is the true state of my body.

My friend’s response, “Very problematic, there are more than a few pro (motorcycle) racers who had to retire just because they broke that bone [the scaphoid]. It wouldn't heal and that was it. Such a small bone, but it can be such a bitch!”

After reading that email I immediately felt the loneliness of retirement and even more so, the loss of identity. I have been managing pain by rationing my martial arts workouts literally for 20 some-odd years. My wrist can only take so much activity. But maybe it is time to face facts. I am a type A personality and not the typical kind of person you find at a meditation class. I love sparring and getting hit and all that, but being type A means that I push it too far too often. Even my wife has been getting on me for instilling the martial ethic into my young son.

All my life I have been type A. When I was picked on in high school by the football team, I didn’t just rollover and take it like everyone else. I started to box, I ran 8 miles a day, punched the heavy bag for hours per day, and I did push-ups and sit-ups. My workouts lasted for hours. My work reaped the success I sought, and by the time I was a junior, I was no longer being picked on. Then when high school was over and I had to get serious about something society valued, I chose to be an artist. Of course in typical type A fashion I again went over the top with drugs, alcohol, and all that comes with that lifestyle. These activities led me to have some minor health issues.

This was the original push to get me to seek out Tai chi, because it is recommended for type A personalities. Many of my injuries and heath issues were linked to this type A drive. I changed many of my habits, like my expression of anger, slamming my fist on a desk, which took a toll on my body. But in time I gravitated back to the more martial aspects of Tai Chi and found a way to keep the martial artist in me alive. In Tai Chi Chin Na I found Jiu Jitsu correlates, and in Tai Chi sword I saw similar characteristics with Kali stick fighting. Again I was using Tai Chi as martial training, not solely as a health exercise, further exacerbating my wrist injuries.

Maybe because of this persistent injury, I am starting to see Tai Chi from a different perspective, as injuries always have a habit of inspiring. I used to think that a Tai Chi master could heal broken bones and beat a 25-year-old professional fighter. When I first started Tai Chi I believed that by simply practicing Qi gong and Tai Chi I could heal my body to a superhuman level. I thought by developing Qi, I would be able to throw a football player 10 feet and that I would never get sick. In my 12 years of serious Tai Chi practice I see that it is not the cultivation of a superhuman ability but some thing far more simplistic. It is the opposite of type A—it is about yielding control and letting things come to fruition on their own. Accomplishing that is harder than breaking coconuts and throwing heavier opponents to the ground.

A famous Tai Chi master came up with a phrase that explains that the essence of Tai Chi; “invest in loss.” This simple concept has been a struggle for me since I began my practice. As a westerner in an eastern practice, I have a hard time reconciling the two approaches. The westerner in me asks, “how did the US become a superpower but by being type A?” Getting to shape the world in a major way is no small accomplishment. Eastern wisdom tells us this is short-term, it will pass. I wholeheartedly agree, but it is comfortable being on top even if it is for a relatively short period of time, like 500 to 1,000 years. Eastern wisdom is beautiful, and it is one of the best ways for all of us to coexist in a world that needs a way of curbing excessive human consumption. If we regulated our desires, many of the issues surrounding global warming could be attenuated.

Giving up martial arts is really hard. It is addictive for me because in martial arts you gain victory by defending against would-be attackers—and to give up creates a certain cognitive dissonance. The whole point of your martial life is to defend yourself. Not being able to do that is to deny everything that you worked so hard to acquire all your life. But just as a champion’s life is so short because there is always going to be someone younger and stronger willing to knock you down for the glory, one must eventually yield.

At this stage in the game for me, Tai Chi is not a miracle cure or a superhuman growth supplement but a form of exercise that can keep me active, which is a miracle in itself. It is also a means of managing pain and that translates directly into living an active life. As it is now with my wrist I could easily stop working out as working out brings pain. Tai chi allows me not to quit and to avoid that slippery slope of inactivity but instead to persevere.

The true power of Tai Chi is a far cry from the hype of internal martial arts promoters for one simple reason: there is no mysterious, esoteric secret. It is the practice of overcoming the part of you that looks for short-term victories and instant gratification. It helps you understand the bigger picture, but with that comes responsibilities and sacrifices. It comes by letting go of your desire to win.

Thursday, August 13, 2009

Is there an inverse relationship between tradition and regulation? A Comparison between Canada and India

Indian culture is one of the oldest if not the oldest living culture still going strong. Without a doubt, one of the factors that generated that kind of longevity is tradition. Regardless of how we might judge tradition with a 21st century lens, a strict family structure with rigid social and cultural norms has got to be one of the reasons for India’s perseverance.

One of the hardest to understand cultural differences between India and Canada is the tradition of marriage. “Dr. Sanjay” (not his real name) is in his 30’s and a typical upper-caste Indian man. He is very handsome and tall but yet single. He is a senior resident doctor of community medicine at PGI. He led a tour of the community health center in Kheri for a group of doctors from North Koreans and myself. The North Koreans doctors, Dr. Sanjay, and I discussed each of our country’s courtship rituals on our way back to PGI medical center. The North Koreans asked if he was married. He said, “no.” As we were discussing this, a beautiful young rural woman passed by our van. I said, “in Canada, if we found her attractive we could approach her and ask her for a date, and if things worked out it is possible to get married. “ Dr. Sanjay said, “That would be next to impossible here.”

Another part of our tour was to observe a public health class. During the class discussion about private and public health, I was invited by the teacher to speak about the Canadian healthcare system. Being an American who lived without health insurance for many years and who now resides in Canada I had a pretty good personal perspective on each system. After sharing my experiences about the Canadian system, the students discussed the Indian health care system. I was impressed by their description of India’s far-reaching delivery of health to its people, but this interaction prompted me to ask an important question: why does Canada have generally very good health outcomes but India has some really poor outcomes?

I began to try to think of reasons and issues besides the obvious ones like population and colonization. This led me to a peculiar realization. India has one of the most rigid social structures on earth, yet the ability for the people to follow government regulations seems like a monumental task. And paradoxically Canada has very little real tradition, and there is no rigid social system. You can walk out of your house and marry anyone you please, and yet if you drive without a seatbelt or on the wrong side of the road you would be severely punished maybe even lose your license. To me the striking difference is a culture of safety—seemingly simple safety regulations that most people in Canada have no difficulty following are almost non-existent in India.

This difference makes me wonder if the health system is the most important way of preventing mortality. This question led me to develop four ideas that, in theory, could take the burden of prevention out of the hands of the health system. These include 1) a general culture of health awareness, 2) stronger regulations, 3) definite and immediate accountability for infractions, and 4) improved infrastructure like clean water, safer roads, sidewalks, etc.

While these are challenging and sometimes expensive endeavors, I have noticed an improvement in some of these areas since my last trip to India, in 2001, in things like public smoking restrictions and at least minimal seat-beat laws. Changing culture is rarely easy, but it won’t happen without starting somewhere. Public safety has to be assimilated into construction, food production, the work place, transportation and any business where people can be harmed by products.

Canada has great infrastructure. Water for human use is filtered and treated to a high degree of purity, roads are safe, and building construction is highly regulated for safety. Contractors and developers can get arrested if they cut corners on building codes, there are elected officials in charge of checking on zoning and building codes of safety, and they have the authority to stop construction or penalize a contractor if unsafe construction practices are used. These regulations are designed for both the construction phase, to protect workers and the public, and for the completed phase, to ensure that buildings don’t collapse or require nearly immediate repairs.

In addition, driving in India is a high-risk activity. On the 5-hour drive from Chandigarh to the Delhi airport, I saw two immediate wrecks probably involving fatalities, three trucks overturned, and numerous automobiles driving on the wrong side of the road. To a North American observer, this disregard of road safety seems to be a point of pride with many Indians, as if they see any demonstration of fear about daily driving habits to be a sign of weakness. This type of cultural myopia is hard to change. When I discussed road safety with many people, they often laughed at our concern and shrugged off the seriousness of accidents. But road accidents in India are extremely high.

According to a Boston Globe article using World Health Organization statistics, “road accidents now are the number two killer of young people age 5 to 29 worldwide…. [In India], an estimated 270 people die each day from road accidents, and specialists predict that will increase by roughly 5 percent a year.”

Many cars do not have operable seat belts, and children ride on motorcycles and scooters without any protection. In Canada this practice is illegal. In fact, it is also so culturally abhorrent that people would call the police and look down on such a person. Because I am a cultural relativist, I don’t judge Indian people who chose to ride a motorcycle with a child, as I understand there are many factors that influence behaviors. But I am concerned about safety. My biggest fear in India is seeing an accident involving a child being slammed onto the asphalt—if I witnessed such an incident I would never forget it.

Much of India’s charm is its stalwart retention of its culture, even in the face of westernization. In Canada, without the long tradition and strong culture, sometimes there is a loss of identity, as people seem to be grasping for something to believe in. Also, such stringent regulations can sometimes be claustrophobic and create a backlash. It is precisely in this dilemma where the public health worker inside me, who believes in safety and longevity as a human right, and the dedicated traveler, who believes that culture is what makes us unique, collide. But I do think a happy medium can be achieved slowly.

Thursday, July 09, 2009

Personal Paradigm Shift

Spending 11 weeks this summer in India, where the heat is 109 degrees and walking 4 days per week, administering surveys door-to-door, negatively affects my daily routine of Tai Chi. It is simply too hot to move. I have been doing some Chi Gung at night before bed. But I still feel like I am missing my daily one-hour routine of Tai Chi. I have felt jealous of my friends back in the US who aren’t missing a beat in their own practice. Then I had an epiphany that led to my own personal paradigm shift.

My choice of going into health research as opposed to acupuncture or some other health care delivery was just the beginning of incorporating my research into my life. Scientific research is a systematic method of adding knowledge about the world around us by collecting data, lots of data. My research here in India is trying to ascertain how people’s dietary habits impact their physiology. What I am finding thus far is that small, simple choices in an individual’s and a culture’s diet can negatively impact their life span. In short, people’s cultures are killing them slowly.

My research in India takes me door-to-door asking people in their homes about their lifestyle choices. Everyday I meet people who are overweight, with high blood pressure, not exercising, making poor dietary choices and of the age where their first MI (myocardial infarction, or heart attack) is not far off. So many of them think that they are healthy and that they are eating just fine. They truly are in a state of denial. The stats tell another story: About 17.5 million people die from cardiovascular related deaths every year. That is 30% of all deaths in the world, which means that CVD kills more people than any other disease.

Although I haven’t been doing as much Tai Chi as I like, I am seeing first hand through a scientific lens that, overwhelmingly, lifespan is determined by the choices people make day in, day out, many of them based on cultural norms. The average life span in India is 64 years of age. The people I meet here are creating a pattern of behavior that will affect their child’s life span as well. Science has given me the tools to see this. By collecting data from hundreds of people I can infer whether a certain behavior is rampant or not. If you just follow a tradition or culture that is orally interpreted or passed down in books you might not notice what is actually happening on the ground. A state of denial is created because tradition is kind of like a rule book or a map following it confirms you are doing well. Unfortunately, many of the directions are flat out wrong or not appropriate to the present time frame. I am finding that the people of India follow their traditions and are very devout, much like people of other places, but unfortunately without that scientific lens they can’t see where the health outcome of their tradition leads. The Hindu religion states the eating of meat is forbidden, with beef strictly taboo. Although the attitude toward chicken is more casual, many people proudly don’t consume it for religious reasons. However, chicken is a more efficient protein, with less fat, than the daily consumption of whole milk (in tea and drunk plain), paneer (a type of cheese), and whole milk yogurt that makes up a big part of the Indian diet.

Even in my beloved Tai Chi there is very little information on dietary behaviors. There is some wisdom on the balancing of the 5 elements and their dietary correlates: sweet, sour, salty, pungent, and bitter. Unfortunately, it doesn’t give any measurements or of course the wise sages could not fore see the transition from a rural old world diet rich in whole grains to a modern diet full of processed refined grains heavy in salt and sugar. Consequently, Tai Chi instructors without training in western science do not pass on that kind of wisdom. The Tai Chi literature also says to avoid any type of cardio activity. Although there is some wisdom within those words when applied to elderly people but it is poor advice for middle-aged adults who are in need a cardiovascular exercise for their heart.

Absorb what is useful, discard the rest

It is difficult not to be influenced by cultural traditions. Tradition gives many of us meaning in life and even makes us aware of many positive activities as well. The Tai Chi literature is full of all kinds of awesome behaviors to follow, that is why I love it and read so much of it but there is a fundamental lack of precision. Following the scientific method gives me the insight of what is actually happening on the ground from the data collected. The choices I make of which many come from the Tai Chi literature are tempered and corrected by the large body of literature amassed by the western science paradigm. So I can as Bruce Lee has advised, “absorb what is useful, and discard the rest.”

Saturday, June 20, 2009

IS there such a force as CHI, QI, or PRANA?

At the very end of the day, this is what we know: physical activity is one of the best activities for preventing a whole array of diseases. Greeks, Indians and Chinese knew this but did NOT or could not empirically prove it. They all created an energetic system of healing. Greeks had Pneuma, Indians have Prana and the Chinese, Chi. But we also know it is it is really hard to exercise everyday, maybe those ancient teachers knew this too?

Until someone actually does a study like one I have designed which isolates Chi practice from physical activity then there can be NO proof of any single activity that people claim cultivate Chi is valid. In other words, all the positive effects of 'Chi' could easily be explained by physical activity. My study would not prove the existence of Chi itself but it could prove that activities which claim to cultivate Chi are more efficacious than running on a trend mill. Maybe one day I will find myself in a situation where I could run that experiment. Or maybe a new technology will come along that measures Chi?

One of the biggest issues in discussing, explaining or even harder, proving Chi is that we have to fuse together two explanatory models about the world. An explanatory model is a structured thought or diagram or paradigm, which attempts to make sense of our world in a simplified way. Hence the only way to explain Chi must be in terms of physics and biophysics. The Chinese had no knowledge of what we would call modern physics but they did understand how to make use of it. This is where we run into problems, I could say Chi is energy but there is a whole field called thermodynamics that also deals with energy. I could say, Chi is the movement of neurotransmitters in the body; again there is a whole field of science that researches this. Unfortunately by applying an old language to a new science much gets lost in translation. Then why use Chi at all? Part of me thinks it is not necessary and part of me thinks that the concept of Chi gives us something to grab onto when explaining complex bodily functions. While leading a lesson on Tai Chi I can’t say, "now let’s feel the release of dopamine and serotonin." It is so much more convenient and accessible to say, "let the Chi sink into your belly." But I also feel it serves another purpose.

The activity of learning and exploring through being thoughtful or mindful is also extremely beneficial towards living a long and healthy life. Many cognitive psychologists are finding that if humans learn something new and complex they are less likely to suffer severe memory loss. Being thoughtful about Chi and its interactions with the complexities of our physiology serves two purposes. One, it keeps my mind active reading higher level material instead of playing video games, which have not proved to prolong memory and two, it motivates me to return to practice, day in and day out. The outcome of which is a highly functional system of cognitive and physiological benefits both inspiring each other. If the mystery of Chi keeps me practicing for 50, 60 or more years than that is quite an achievement by itself.

The paradox of physical exercise is that our minds know it is good for us but the mind has to motivate the body to get up and do it consistently for there to be any benefit. What if the mystery of Chi Gong is so complex that is can not be empirically 'figured out' as so many of us try? That makes it the ultimate cliffhanger created by a most wise sifu. If you ever have a chance to meet one of these people after-death or otherwise, and you finally get to ask that one burning question that has been tugging at you for years, "is Chi real?" Sifu would say, "the mind is dumb and the body is the smart." "Ah ha," you say, "I knew it was a trick all along." And before that smugness has a chance to settle, the sifu responds, "But the mind always has to be right."

Friday, May 22, 2009

Tai Chi below Shannon Falls in BC

The practice of the Tai Chi form reaches its apex for me when performed in nature. The first step in learning the Tai Chi is the basics. Once the body mechanics are understood, the applications of each posture need to be comprehended. This develops an ability that demonstrates good structure. Structure is how the body handles pressure. Bad structure collapses under pressure and good structure does not. Once these elements are understood on a general level the most satisfying part of Tai Chi is not being able to defeat multiple attackers, but simply moving and interacting with nature. When you feel you are able to follow nature and understand it as if you were the rider and it was a horse, you are in a place to realize a deeper part of yourself and to improve upon the many weaknesses you endure while living in this complicated world.

Please do not take these words as some type of fixed idea that you complete one step, the basics, then another and so on to the final stage of development, rather take them as a process. By looking at your learning as a work in process, you can shed the idea that there is some kind of fixed state, and you might be easier on yourself.

Sometimes we work the basics and move on to realization, and back to applications, then realize that you totally forgot the basics and have to start all over. The process of Tai Chi can be frustrating but it is important to be easy on yourself and remember to love what you are doing and then do it often.

Wednesday, May 20, 2009

My letter to Barack Obama about Health care in America

I am a 44 year old American in graduate school in Canada. I am seriously considering applying for citizenship there. The major justification for this decision would overwhelmingly be free health care.

Since I have been there I have not had to battle ANY health care request, whereas my experience in the United States has been quite the opposite. I have had wrist pain for the past 20 years. I have been to multiple doctors in the US. None of them ever addressed the issue without first suggesting pain killers as the solution. While the idea of relying on painkillers is good for the pharmaceutical industry, it is repugnant to me. I then retreated to alternative health care as so many Americans do. Alternative treatments brought me some success but the pain continued. Finally, in Canada, a doctor had a novel idea, a CT scan. I was finally correctly diagnosed, after 20 years with a broken scaphoid bone in my wrist.

I know that a small broken bone doesn't sound like a traumatic disease that has ravaged my life, but I have made major changes to my life because of it. I have been physically active all my life and there are many enjoyable activities and some jobs that I can no longer perform. It is also significant in that it is so small but yet for America so large and expensive.

I have an appointment this September with an orthopedic surgeon in Canada. I feel confident that if he thought he could repair my wrist with a costly surgery, there would be no obstacles in my way. Unlike his American counterpart who would gladly offer the surgery, but then I would have to figure out how to pay for it. In the US, I had to drop health insurance because the $500 per month was too high and my policy probably didn't cover it anyway, because it would have been a ‘preexisting condition.’

The irony of all this is that the injury happened while I was working my way through college in my 20's. I find it ironic because while contributing to the economy I was injured. I was too young to realize the implications of my injury. As an older man the pain from my wrist has a place at the table when decisions are made. I have to listen to it before I engage in certain activities and even certain jobs. Amazingly, even conservatives in Canada realize the importance of single payer health care. The irony continues because here I am at the peak of my ability to contribute to the economy but my country will not assist in my health, and a country not of my birth will gladly do what it is right. As I get older health increasingly becomes a top priority, so how can I resist an excellent opportunity that will insure my health into my golden years?

Tuesday, January 06, 2009

Why I Chose a Career in Public Health....

When I re-entered University at age 39, my purpose was to get a better job in the health-care field. My top choices were physical therapist, psychological counselor, or acupuncturist. During my first semester I began to see that physical therapy was much like a car mechanic and that the daily work would be fixing people's knees and other parts that were broken and, most importantly, that PTs don't have as much autonomy as I'd like. The doctor diagnoses the injury and prescribes the regime. I was much more interested in the mind's role in healing and prevention. In psychological counseling the therapist works with patients on a number of behavioral issues, not just physical health. I began to research health psychology. Around the same time, I found some studies on acupuncture that questioned its ability to heal any disease, and there was no real emphasis on prevention. After many years of studying Taoist healing practices that focus more on prevention than acute repair, I wanted to help prevent disease from beginning in the first place.

Near the same time, a friend passed on a book entitled The Status Syndrome by Michael Marmott. In it the author explained that diseases manifest themselves in a population differently with regards to social class. People at the top of the social hierarchy live longer than people at the bottom, including the radical discovery that people with PhDs generally live longer than people with a Master's degree and right on down the line. The issues raised in that book caused me to have a spiritual crisis and led me to pursue a career that relies less on religious faith and more on personal empowerment and education. It also sparked a strong desire for discovering an empirical basis to substantiate claims about efficacious healing practices.

In addition, I grew increasingly frustrated about our western health system, which is based on a model designed to combat acute trauma and infectious diseases. Unfortunately, that model is ineffective in preventing non-communicable diseases (NCDs) because they are about lifestyle choices made by the individual, heavily influenced by cultural norms and pressures.

The western medical system approach is top-down, meaning that doctors tell patients what to do. Because of medical advances over things like bacteria—which have been great in reducing infectious diseases and the burden of those on hospitals and communities—doctors and the medical establishment have been given too much power over areas where they are not particularly effective. This kind of power has a tendency to narrow people's vision, so that the current model is excessively preoccupied with physiology and the view that everything is biologically determined. So the focus is on high-ticket items like surgery rather than cost-effective, preventative, lifestyle changes.

For non-communicable diseases such as cardiovascular disease and diabetes, the need is greater than ever to create a system that can raise awareness and motivate people to change high-risk behaviors. This approach aims to keep people out of the hospital for things like heart surgery by keeping them healthy in the first place.

This is why I look to other, decentralized health systems as a model for dealing with education and prevention issues. Systems like those at various times in Bangladesh, Cuba, Pakistan, the state of Kerala in India, China, and the parts of the Philippines have designated roles for ordinary people to become community health educators. These people function as disseminators of information to rural regions where doctors are unable to access. These decentralized systems accomplish two amazing things. First, the distribution of medical knowledge creates a less hierarchical system in which more people can share in the decision making process. Second, and most important, these community educators more easily reach marginalized groups, which often have a heavy burden on healthcare systems. Using education programs between people who are on the same status level is an effective tool alongside a top-down authoritarian approach.

When it comes to many diseases—particularly non-communicable ones—awareness is an essential ingredient in preventing a disease from becoming a major player mortality rates. And so much of maintaining good health is about having access to information. For example, we are seeing a reduction of cigarette smoking in developed countries because more people in those places have become educated about the overwhelming evidence about the dangers of cigarette smoking. In less developed countries, there has been an increase in smoking because those places have not been able to enact effective campaigns about the ills of cigarette smoking. But in due time, we will see a reduction in cigarette smoking in those places, too, as health education systems have time to catch up. As with cigarette smoking, condom usage, diet, exercise, clean water and clean hands, many other preventative behaviors can also be taught and learned.

All these issues combined to lead me to a degree program in public health, with an emphasis on non-communicable diseases. For me, public health can be the “ounce of prevention [that] is worth a pound of cure.”