Exploiting marginality in health: Is ‘subhealth’ another case of disease mongering? Dr. Benjamin T.Y. Chan University of H...
Conceptual issues <ul><li>‘ Medicalization’ and ‘Disease Mongering’ treat the concept of disease as a problem </li></ul><u...
What is ‘subhealth’ 亞健康 ? <ul><li>A condition uniquely known in China that is not classified as a disease, but still requi...
The subhealth condition is characterized by: <ul><li>fatigue </li></ul><ul><li>lethargy </li></ul><ul><li>depression </li>...
<ul><li>Subhealth is associated with the high tempo of life in a modern society. Its causes are multifaceted: </li></ul><u...
Reported Prevalence of ‘subhealth’ <ul><li>Subhealth epidemiological survey in ‘China Youth Daily’ covering 51,303 respond...
<ul><li>Subhealth is believed to be most prevalent among while collar workers and intellectuals with high education level....
Problematization of ‘health’ <ul><li>WHO defines health as: </li></ul><ul><li>“ a state of complete physical, mental and s...
Three-dimensional representation of health Source: p.95 FD Wolinsky (1988) The Sociology of Health, 2 nd  ed. p.95
Eight health states in the three dimensional model Health State 1 2 3 4 5 6 7 8 Label Normally well Pessimistic Socially i...
<ul><li>The three-dimensional model does not provide the answer to the definitional problem of health. Issues to be tackle...
Chinese health researchers’ response to the problem of defining health is to propose a ‘dynamic transformational model’: H...
The representation of health, subhealth and disease is A  B +  C  D  where: +  C = Health  D  - = Disease A  B = Subhealth...
The significance of the ‘dynamic transformational model’ is to provide appropriate bases for looking after these various s...
Why ‘subhealth’ fits within the same problem framework of ‘medicalization’ and ‘disease mongering’? <ul><li>Subhealth has ...
To understand subhealth and its influence on the Chinese health scene, a three-part analysis is given: <ul><li>Constructio...
Construction of subhealth as a condition <ul><li>Pre-initiation stage (From mid-1980s) </li></ul><ul><li>Soviet influenced...
<ul><li>Haier supported the first ‘Academic Seminar on Subhealth’ held in Beijing in May 1997 under the auspices of the Ch...
<ul><li>3 rd  Academic Seminar on Subhealth held in August 2001 at Haier Pharmaceutical Company’s headquarter in Tsingtao ...
Post-initiation stage (2002-present) <ul><li>‘ China Academic Seminar on Subhealth’ is now an annual event sponsored by va...
Construction of diagnosis and treatment for subhealth <ul><li>Subhealth condition being distinct from disease state requir...
Examples of diagnostic methods <ul><li>1. Health evaluation </li></ul><ul><li>MDI (ICD-10) </li></ul><ul><li>85-100 health...
<ul><li>2. Microscopy Diagnostic Instrument (MDI) </li></ul><ul><li>Most commonly used version is the Tsinghua Multimedia ...
MDI is commonly referred to as “A drop of blood test”
<ul><li>3. Thermal Texture Maps (TTM) </li></ul><ul><li>A non-invasive imaging technology that can provide functional (as ...
TTM is commonly referred to as “Hot CT”
<ul><li>Examples of treatment </li></ul><ul><li>Chinese medicine and health food </li></ul><ul><li>‘ Cai Li’  采力  is the o...
<ul><li>2. Subhealth treatment is available in specialized medical centers. Salient examples are given below: </li></ul><u...
<ul><li>Tianjin First Center  天津第一中心  Hospital is the first one to establish a Subhealth Rehabilitation Center in 2000. It...
High voltage static electricity therapy Music therapy Float therapy
Construction of channels for propagation and further research <ul><li>Subhealth is a topic of recurrent interest in the po...
<ul><li>There are evidences to suggest that the subhealth concept is starting to spread outside of China. Examples include...
<ul><li>Research on subhealth has been steadily increasing since 1996 and the number of publications indexed in the China ...
<ul><li>According to the bibliometric study of Liu et al. (2004)*, the breakdown of themes in subhealth research articles ...
<ul><li>The majority of research papers are published in lower-tiered journals with a few excellent ones appearing in The ...
Observations <ul><li>Subhealth is a unique form of socio-cultural construction of health and illness in a society that is ...
<ul><li>Subhealth offers non-orthodox modalities a chance to secure their niche in the fee-paying health market </li></ul>...
<ul><li>Recommendations </li></ul><ul><li>To refine the determination and specify diagnostic criteria for grades of subhea...
<ul><li>In its current usage, ‘Minor subhealth’ would be reflected by indicators from the physical and psychological group...
<ul><li>To re-orient subhealth concern from profit motive to the safeguard of public health, a focus on chronic disease pr...
<ul><li>Impact of chronic disease in China </li></ul><ul><li>Facts: </li></ul><ul><li>In China, chronic diseases are proje...
Projected deaths by cause, all ages, China, 2005 Source: WHO, http://www.who.int/chp/chronic-disease_report/en/
<ul><li>Conclusion </li></ul><ul><li>Subhealth can be a force for good in furthering understanding of health and in achiev...
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Exploiting Marginality In Health: Is Subhealth Another Case of Disease Mongering

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Presented in Inaugural Conference on Disease Mongering, Newcastle, Australia, April 11-13, 2006

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Exploiting Marginality In Health: Is Subhealth Another Case of Disease Mongering

  1. 1. Exploiting marginality in health: Is ‘subhealth’ another case of disease mongering? Dr. Benjamin T.Y. Chan University of Hong Kong, SPACE
  2. 2. Conceptual issues <ul><li>‘ Medicalization’ and ‘Disease Mongering’ treat the concept of disease as a problem </li></ul><ul><li>‘ Subhealth’ treats the concept of health as a problem </li></ul>
  3. 3. What is ‘subhealth’ 亞健康 ? <ul><li>A condition uniquely known in China that is not classified as a disease, but still requires treatment </li></ul><ul><li>A state that exists between health and disease, a so called ‘third state’ forming the continuum between health and disease </li></ul><ul><li>A concept whose formation has direct backing from corporate interest and involves the skillful use of media as vehicle for its popularization </li></ul>
  4. 4. The subhealth condition is characterized by: <ul><li>fatigue </li></ul><ul><li>lethargy </li></ul><ul><li>depression </li></ul><ul><li>slow reaction </li></ul><ul><li>insomnia </li></ul><ul><li>agitation </li></ul><ul><li>poor memory </li></ul><ul><li>poor concentration </li></ul><ul><li>social withdrawal and loneliness </li></ul><ul><li>prone to illness </li></ul><ul><li>and many more…… </li></ul><ul><li>panic </li></ul><ul><li>dizziness </li></ul><ul><li>headache </li></ul><ul><li>indigestion </li></ul><ul><li>shortness of breath </li></ul><ul><li>sweating </li></ul><ul><li>aching and pain in the waist and legs </li></ul><ul><li>poor social relationship </li></ul><ul><li>feeling sick </li></ul>
  5. 5. <ul><li>Subhealth is associated with the high tempo of life in a modern society. Its causes are multifaceted: </li></ul><ul><li>Social, psychological, environmental, genetic, and unhealthy lifestyles, habits and behaviors </li></ul><ul><li>Subhealth is related to occupational stress and mental fatigue. </li></ul><ul><li>Teachers, students, medical workers, engineers and technicians </li></ul>
  6. 6. Reported Prevalence of ‘subhealth’ <ul><li>Subhealth epidemiological survey in ‘China Youth Daily’ covering 51,303 respondents nationwide revealed that: </li></ul><ul><li>20.87% are healthy;58.18% are in a subhealth state;5.62% are diseased;13.38% are unsure about their state of health </li></ul><ul><li>China Health Care Association survey of 16 cities with population greater than 1 million revealed that: </li></ul><ul><li>75.31%, 73.49% and 73.41% of residents in Beijing, Shanghai and Guangzhou respectively are in a subhealth state </li></ul>
  7. 7. <ul><li>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 </li></ul><ul><li>Media participates in fanning scare about consequences of untreated subhealth leading to chronic diseases, sudden and early death </li></ul>
  8. 8. Problematization of ‘health’ <ul><li>WHO defines health as: </li></ul><ul><li>“ a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” </li></ul><ul><li>This definition does not provide a conceptual scheme in which to evaluate the complete spectrum between health and illness that includes the three dimensions </li></ul><ul><li>American medical sociologist, F.D. Wolinsky, has attempted to address this problem by constructing a three dimensional typology </li></ul>
  9. 9. Three-dimensional representation of health Source: p.95 FD Wolinsky (1988) The Sociology of Health, 2 nd ed. p.95
  10. 10. Eight health states in the three dimensional model Health State 1 2 3 4 5 6 7 8 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, 2 nd ed. p.97-98
  11. 11. <ul><li>The three-dimensional model does not provide the answer to the definitional problem of health. Issues to be tackled as identified by Wolinsky include: </li></ul><ul><li>Evaluation of each health state identified </li></ul><ul><li>Evaluation of the relationships among these health states </li></ul><ul><li>Delineating process of transition from one health state to another </li></ul><ul><li>Examining weighting factor for each dimension in contributing to a composite health status </li></ul><ul><li>Describing process of interaction between the three dimensions </li></ul><ul><li>Delineating relationship of health states to the larger social system </li></ul>
  12. 12. 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
  13. 13. The representation of health, subhealth and disease is A B + C D where: + C = Health D - = Disease A B = Subhealth AC = Overlap between health & subhealth DB = 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
  14. 14. 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
  15. 15. Why ‘subhealth’ fits within the same problem framework of ‘medicalization’ and ‘disease mongering’? <ul><li>Subhealth has effectively acquired a quasi-disease label </li></ul><ul><li>Subhealth is defined mainly by corporate-influenced agenda rather than genuine public health concerns </li></ul><ul><li>Subhealth has aroused national interest through widespread media coverage </li></ul><ul><li>Subhealth gives rise to a number of products and services that aim to ameliorate or provide recuperation for this condition </li></ul>
  16. 16. To understand subhealth and its influence on the Chinese health scene, a three-part analysis is given: <ul><li>Construction of subhealth as a condition </li></ul><ul><li>Construction of diagnosis and treatment for subhealth </li></ul><ul><li>Construction of channels of propagation and further research </li></ul>
  17. 17. Construction of subhealth as a condition <ul><li>Pre-initiation stage (From mid-1980s) </li></ul><ul><li>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 </li></ul><ul><li>Initiation stage (1996-2002) </li></ul><ul><li>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 </li></ul>
  18. 18. <ul><li>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) </li></ul><ul><li>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 </li></ul><ul><li>2 nd 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’ </li></ul>
  19. 19. <ul><li>3 rd 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’ </li></ul>Subhealth: a new concept of health in the 21 st century by Wang Yu Xue (2002). Jiang Xi Science and Technology Press
  20. 20. Post-initiation stage (2002-present) <ul><li>‘ 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. </li></ul><ul><li>‘ 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 </li></ul>
  21. 21. Construction of diagnosis and treatment for subhealth <ul><li>Subhealth condition being distinct from disease state requires diagnostic methods that are different from clinical chemistry and conventional medical imaging technology </li></ul><ul><li>Subhealth treatment draws from the modalities of Chinese medicine, rehabilitation medicine and health food </li></ul>
  22. 22. Examples of diagnostic methods <ul><li>1. Health evaluation </li></ul><ul><li>MDI (ICD-10) </li></ul><ul><li>85-100 health; 70-85 subhealth; <70 disease </li></ul><ul><li>Delphi method derived diagnostic criteria made up of 18 symptoms divided into 6 groupings </li></ul><ul><li>SCL-90 (Symptom Checklist-90) </li></ul><ul><li>CMI (Cornell Medical Index) + SCL-90 + EMBU (Egna Minnen Betraffande Uppfostran)* </li></ul><ul><li>*EMBU assesses adults’ memories of parents’ rearing practices </li></ul>
  23. 23. <ul><li>2. Microscopy Diagnostic Instrument (MDI) </li></ul><ul><li>Most commonly used version is the Tsinghua Multimedia Computing interface </li></ul><ul><li>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 </li></ul><ul><li>Live blood cells can be observed and a spectrum of blood cell profile is used to explain derangement in organ functions </li></ul>
  24. 24. MDI is commonly referred to as “A drop of blood test”
  25. 25. <ul><li>3. Thermal Texture Maps (TTM) </li></ul><ul><li>A non-invasive imaging technology that can provide functional (as against anatomical) information of living cells </li></ul><ul><li>The thermal-infrared imaging slicing technology is developed by Chinese scientist Liu Zhong Qi (Beijing Industry University) and patented in the US </li></ul><ul><li>It detects heat generated by metabolic activities of living cells and is capable of discriminating healthy and diseased tissues </li></ul>
  26. 26. TTM is commonly referred to as “Hot CT”
  27. 27. <ul><li>Examples of treatment </li></ul><ul><li>Chinese medicine and health food </li></ul><ul><li>‘ 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. </li></ul>Chinese medicine form Health food form
  28. 28. <ul><li>2. Subhealth treatment is available in specialized medical centers. Salient examples are given below: </li></ul><ul><li>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 </li></ul><ul><li>Beijing Kang Ya 康亞 Hospital is a private hospital and the first one to be dedicated entirely to the diagnosis of subhealth condition </li></ul>
  29. 29. <ul><li>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 </li></ul><ul><li>Countless other units exist around the country and they are all characterized by their aggressive marketing strategies and profit orientation </li></ul><ul><li>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 </li></ul>
  30. 30. High voltage static electricity therapy Music therapy Float therapy
  31. 31. Construction of channels for propagation and further research <ul><li>Subhealth is a topic of recurrent interest in the popular health media in China </li></ul><ul><li>Subhealth dedicated websites (virtually all of them are commercially sponsored) are impossible to count </li></ul><ul><li>The most important and well-known portal for subhealth information is at http://www.subhealth.com </li></ul>
  32. 32. <ul><li>There are evidences to suggest that the subhealth concept is starting to spread outside of China. Examples include the following: </li></ul>US Chinese medicine commercial website Hong Kong Health Journal March 2005 (paid advertisement)
  33. 33. <ul><li>Research on subhealth has been steadily increasing since 1996 and the number of publications indexed in the China Journal Net database reflects this trend </li></ul>
  34. 34. <ul><li>According to the bibliometric study of Liu et al. (2004)*, the breakdown of themes in subhealth research articles are </li></ul>26.89% of the total belong to TCM research *Chin. J. Mod. Med. (2004) 14(17):155-156
  35. 35. <ul><li>The majority of research papers are published in lower-tiered journals with a few excellent ones appearing in The Chinese Journal of Epidemiology </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>
  36. 36. Observations <ul><li>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 </li></ul><ul><li>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 </li></ul>
  37. 37. <ul><li>Subhealth offers non-orthodox modalities a chance to secure their niche in the fee-paying health market </li></ul><ul><li>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 </li></ul><ul><li>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. </li></ul>
  38. 38. <ul><li>Recommendations </li></ul><ul><li>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 </li></ul><ul><li>The diagnostic criteria are arrived at through 2 rounds of expert consultation based on Delphi method </li></ul><ul><li>There are 18 symptoms divided into 6 groupings (physical, psychological, vigor, social adaptability, immunity, medical consultation) </li></ul><ul><li>Each of the symptom groupings has 4 levels of response </li></ul>
  39. 39. <ul><li>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 </li></ul>
  40. 40. <ul><li>To re-orient subhealth concern from profit motive to the safeguard of public health, a focus on chronic disease prevention is necessary. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  41. 41. <ul><li>Impact of chronic disease in China </li></ul><ul><li>Facts: </li></ul><ul><li>In China, chronic diseases are projected to account for 79% of all deaths. </li></ul><ul><li>WHO projects that over the next 10 years in China: </li></ul><ul><li>Over 80 million people will die from a chronic disease. </li></ul><ul><li>Deaths from infectious diseases, maternal and perinatal conditions, and nutritional deficiencies combined will increase by 2%. </li></ul><ul><li>Deaths from chronic diseases will increase by 19% - most markedly, deaths from diabetes will increase by 50%. </li></ul>
  42. 42. Projected deaths by cause, all ages, China, 2005 Source: WHO, http://www.who.int/chp/chronic-disease_report/en/
  43. 43. <ul><li>Conclusion </li></ul><ul><li>Subhealth can be a force for good in furthering understanding of health and in achieving a definition of health based on empirical constructs. </li></ul><ul><li>However, the rigor of research should be strengthened and separated from political and economic interests to reclaim its scientific merit. </li></ul><ul><li>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 </li></ul>

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