Facing Up to Chronic Disease

MONTREAL – Many of us are terrified by the prospect of having a debilitating stroke or a fatal heart attack. Few of us, however, respond as emotionally to the threat of chronic disease, a vague and elastic term that is mainly useful for organizing health services. And yet chronic disease has become a major social problem that requires a collective response.

Historically, chronic disease referred to conditions lasting over a long period. But, with the increasing organization of medicine around specific diseases, the term has come to refer to an open-ended set of conditions including cardiovascular disease, cancer, and diabetes, but not infectious diseases, such as tuberculosis and malaria, or mental illness.

In the nineteenth century, chronic disease was considered problematic in part because sufferers took up scarce beds in hospitals that were increasingly focused on treating acute, curable diseases. But chronic disease soon became a wider public-health issue as the death toll from cancer, cardiovascular disease, and diabetes seemed to rise. In fact, the initial increase in the number of reported deaths from these diseases most likely reflected better identification and diagnosis. Filling in death certificates is not an exact science, and doctors focus on causes with which they are familiar.

Over time, though, the incidence of chronic disease almost certainly did rise in developed countries. As infectious diseases have been brought increasingly under control, more people live into old age, when they become susceptible to long-term illnesses. As a result, chronic diseases now comprise a large proportion of health-care systems' total caseloads.

Our collective interest in addressing the problem of chronic diseases does not rest only on epidemiological statistics. It also reflects deep, long-standing concerns about the effects of civilization: urban overcrowding, sedentary lifestyles, unhealthy habits like tobacco and alcohol consumption, overeating, and stress. Moreover, we have come to believe that most diseases, including previously hopeless conditions, can be prevented, cured, ameliorated, or controlled by scientific medicine, and that even those patients unlikely to benefit have a right to medical care.

As chronic disease has become an increasingly prevalent social problem, it has been dealt with in two ways. The most common response is disease-specific. The American Cancer Society and the American Heart Association, as well as the disease-based research institutes of the National Institutes of Health, are notable examples.

An alternative approach is to treat these illnesses as a single, comprehensive problem. The earliest example occurred in the United States, where a focus on welfare measures and health insurance for vulnerable populations – the elderly, the disabled, and the very poor – led to a strong push to confront the chronic diseases widespread among them. European countries, preoccupied with national health-care systems that addressed the needs of the entire population, took longer to move toward comprehensive strategies.

Both approaches have given rise to new forms of epidemiological surveillance. Since the 1950s, for example, the field has been extended to risk factors, a concept that grew out of debates about the health effects of tobacco and studies of cardiovascular diseases with multiple potential causes. Some risk factors – moderate hypertension and high cholesterol, for example – have themselves become chronic diseases, requiring medical (and sometimes surgical) treatment and further contributing to the rise in illness rates.

A new vision of health care, which has grown out of the US managed-care movement, has recently heightened the relevance of embracing a comprehensive approach to treating these conditions. Originally intended to cut costs, the goal now is to provide more appropriate care for a new era, the premise being that long-term care for many diseases requires forms of medical organization that are different from those geared toward acute care. Acute episodes and expensive hospitalization can be avoided by providing expert team support for patient self-care.

The most successful and radical of these initiatives is the Chronic Care Model developed by Edward Wagner, an American doctor. Less sweeping is the Medical Home Model, also developed in the US, which seeks to create teams of caregivers to provide better access and continuity of care to patients suffering from multiple diseases.

Massive health-care systems cannot shift course easily or quickly. But efforts like these, by focusing on the need to provide appropriate and less expensive care for chronic diseases, constitute a small step in the right direction.