The healthcare system of a country goes beyond the individual provider and involves mechanisms that are structural, economic and organisational. It is seen as a specialised sub-system of society. Even though nation-states have a variety of coexisting systems of health delivery, all of them in totality represent the health system of that society.
It is by virtue of being a subset of the larger society that a health system must possess a pastoral component. This component provides support and reassurance to the suffering and often psychologically-regressed persons and has a strong fiduciary element. After all, the purpose of the healthcare system is to address the illnesses and diseases that plague societies and heal them as far as possible. Healing requires relationships—relationships which lead to trust, hope and a sense of being known.
Being a subset of changing societies, health systems have also evolved. A tectonic shift in the functioning of health systems appeared when the world moved from an agricultural mode of subsistence to an industrial one. As time passed, two elements appeared to be at the base of many critical structural changes in the medical system of contemporary industrial society. These were increased availability of bio-medical knowledge and its application to the solution of medical problems, and a surging effective demand for services on the part of society.
A simultaneous development on the psychological front in a postmodernist society was that of depersonalisation, a concept that since its origin has mainly been studied as a ‘disorder’ in clinical populations. It was described as a state in which an individual experiences feelings, thoughts, memories, or bodily sensations as not belonging to oneself. What we know as depersonalisation today, although not articulated in such a manner, has been recorded in people since 1828. But as societies evolved from agricultural to industrial to technological the major forms of the mental health condition evolved as well.
Depersonalisation disorder, or DPD, has unclear boundaries, conceptually as well as vocationally and affects people from all walks of life. It is among the most common yet under-recognised psychiatric conditions in the world. According to studies in both Britain and the US, DPD could affect up to 2% of the population – that is, around 1.3 million people in the UK, and 6.4 million in the US. Hence, it is not surprising that health care professionals who are, after all, members of society, experience and manifest characteristics of the same condition. It is in the context of the whirlwind modern life that depersonalisation is described as a defensive coping strategy, where an individual limits one’s own involvement with others and creates a psychological distance. Through such response the individual tries to create an emotional buffer between oneself and the imposed job demand.
In the context of depersonalisation this becomes pertinent when the system offers the services of approximately 200 physicians and well over 1,000 other personnel to nearly 200,000 members and thus the potential for depersonalisation is high. Brian Abel-Smith once said, “Countries had poor health because they were poor and to some extent they were poor because they had poor health.” Upon studying weak health systems in poor countries, it was found that the situation is exacerbated by public health services that have been seriously weakened by chronic underfunding and loss of personnel, with an accelerating “brain drain” that is reaching crisis proportions and raising ethical questions regarding recruitment by wealthy countries.
At this juncture it is important to distinguish between depersonalisation and dehumanisation. David Hayes-Bautista uses personalisation-depersonalisation to signify the relative number of human providers participating in care and humanisation-dehumanisation to describe the relative degree of humanism practiced by those in attendance. It is important to remember that although highly damaging in their own respect, the two cannot be equated. For instance, for a pregnant woman to experience little to no time with her gynaecologist where she can ask queries about her diet, exercise, etc. would be depersonalisation. But for the same woman to experience physical and verbal abuse during labour with loss of agency would be dehumanised treatment. In that respect, complaints about waiting time, rotation of physicians and message centres may well be considered criticisms of depersonalisation even though the term or a synonym is not used.
Over the course of the last century, biological science has become increasingly reductionist in its view of humans, fragmenting the whole person into parts and problems and converting human beings into “things,” through objectification. Knowledge advanced greatly in the modern era by making sense of complicated things by understanding their parts. This led to an ensuing rise in specialisation in health care which led to breathtaking advances from isolating, partitioning, and manipulating the components of physical, biological, and human systems. It is here that the fragmentation, specialisation and deprofessionalisation in health care cross paths with depersonalisation. The result is that emphasis on empirical and scientific elements in modern medicine is progressively crowding the pastoral elements out of the medical role, often leaving patients emotionally and psychologically stranded.
Advances in technology can be liberating forces if they increase the quantity, quality and variety of options available to patients and practitioners. But how technology has taken over the definition of the health care system is controversial. The problem with this is the obvious concern that most specialised and technology-intensive care is inaccessible to majority of the people, especially in developing countries. A review of literature on inequalities in access to curative care gives some empirical support for this view, finding more class inequality in specialist care and less class in primary/GP care, across several healthcare systems. But in the context of depersonalisation, technology can affect the perceptions of health professionals. In intensive care, coronary care and end-of-life care, it may be questionable where the patient leaves off and some mechanical apparatus begins.
This is a moot point for the existence of the health care system which should heal the person and not just the disease. Holistic healing involves the transcendence of suffering. Suffering arises from perceptions of a threat to the integrity of personhood, relates to the meaning patients ascribe to their illness experience, and is conveyed as an intensely personal narrative. When the system slowly but systematically alienates components that allow patients and doctors to foster a relationship, the more evident healthcare crises of unsustainable cost, lack of quality and inequity emerge. Even physical designs of health-care settings (e.g., bench-lined, bile-green corridors devoid of decoration or recreational detractions) can generate or aggravate a sense of depersonalisation.
It is the poor generalist health professional who considers only the disease and not the whole person. Consequently, it is the poor policy maker that designs health care systems that deal only with discrete diseases and fails to create environments that support creative interaction between different parts of the system. The health system cannot exist in a silo of clinical acumen but must acknowledge its place in the societal system. As we engage in a discourse on the crumbling public health system of the country, it becomes imperative to identify the features of health care which contribute to depersonalisation of its providers and weaken the system.
The objective is not to oversimplify the mounting healthcare problems of poor quality and inequity and lay it all on bio-medical technology and modern medicine as triggers of depersonalisation. The objective is to understand depersonalisation in a personalised way by looking at its manifestations in health care and highlighting factors and practices that feed into it. While depersonalisation is only one issue, it is significant because it relates so strongly to the issue of psychosocial effectiveness, which is a vital component of overall organisational effectiveness. The ways in which the effects of depersonalisation can be ameliorated are manifold because the system itself is complex and has intra- and inter-sectoral linkages. But what is important is to go back to the roots of humanism based on which the system has been envisaged.
Continuity of care and comprehensive communication should take precedence over efficiency and economy. Procedures such as rotation of physicians, non-reporting of negative findings, and pooling of messages should be re-evaluated periodically. Personalised medicine, also known as precision medicine, which fundamentally encompasses the tailoring of medical treatment on the basis of individual patient characteristics, needs and preferences to improve outcomes should be incorporated. Lastly, as heralded by William Osler, there is a need to move from doctor-centred approach to a patient-centred approach utilising methods like cone-questioning technique to re-infuse the health care system with the pastoral component it began with but slowly lost out on the way.
Surbhi Shrivastava is a postgraduate student of public health in health policy, economics and finance at the Tata Institute of Social Sciences, Mumbai.