The Path to Wellness : Dr Ketan Desai

The “Taro Takemi Memorial Oration” delivered by Dr Ketan Desai at CMAAO 34th General Assembly

“Ladies and Gentleman

It gives me immense pleasure to record my committed sense of appreciation for the Indian Medical Association and its office bearers who have taken this historically notable initiative of organizing the 34th CMAAO General Assembly and 55th Council Meeting in the midst of the scenic beauty of Goa, which is bound to the memorable by all yardsticks.

I also consider it a privilege conferred on me to deliver this prestigious oration on a theme which is very apt, timely, relevant and of vital and significant need in the context of contemporary and long term challenges that the health systems in vogue across the Globe are plagued by.

It is pertinent to note that rightly the World Health Organization has defined the concept of health as ‘not just the absence of infirmity or disease but a total sense of wellbeing in all the domains namely the physical, emotional, social, intellectual, mental and spiritual as well’. As such, it by itself brings to fore that it contemplates the entitlement of every Global Citizen to a sense of ‘positive health’ which is a mirror image of the desired sense of ‘wellbeing’, which finally connotes ‘wellness’.

The essence of the concept of ‘wellness’ is depicted in the Vedic literature as well wherein Wellness as a concept or idea is best defined in Atharvaveda in Sushruta Samhita through one of its hymns, which states that :

समदोषः समाग्निश्च समधातुमल क्रियः। प्रसन्नात्मेन्द्रियमनाः स्वस्थ इत्यभिधीयते। सुश्रुत सूत्रस्थानः 16∕48

(“sama dosha sama agnischa sama dhatu mala kriyaaha| Prasanna atma indriya manaha swastha iti abhidheeyate |)

The contours in the said hymn bring out that one is in perfect health when the Three Doshas (movement, metabolism and structure), Digestive fire (digestion, assimilation and metabolism of the body as well as the microbiome), Dhatus or seven tissues (Rasa, Rakta, Mamsa, Medha, Asthi, Majja, Shukra or Plasma, Blood, Muscle, Adipose Tissue, Bone, Bone Marrow and Reproductive Fluids ) all the excretory functions (urination, sweating, defecation, menstruation) are in perfect order with a joyful and contented mind, senses ( 5 motor and 5 sensory) and spirit or consciousness.

As such, the most important aspect of health contributing to wellness is therefore believed to be a contended mind, senses and the consciousness.

The four steps of Joy are: Shanti (quiet undisturbed mind), Vichara (soul searching), Santosha (contentment) and Satsanga (company of good people indulging into the path of truthfulness).

Yajurveda brings out yet another revelation “Yatha pinde tatha brahmande, yatha brahmande tatha pinde”, which means that as is the macrocosm so is the microcosm. This tells us to follow the path of nature as everything in environment reflects the same changes that take place correspondingly in our body. The sum and substance thereto goes to emphasize that the path of wellness of an individual is to: Unlearn the wrong habits and lifestyle, learn the right habits and practice right actions thereto.

Correspondingly the modern literature brings out the concept of ‘wellness’ be a state of wellbeing and process that applies to the ‘whole person’. The 10 dimensions of the wellness have been catalogued to the effect that it includes:

• Social, which contemplates family and social support including cohesion
• Physical, contemplates physical vitality, active lifestyle practices, structured exercise
• Environmental, contemplates living condition and physical surroundings for immediate to Global
• Medical and Dental contemplate screening prevention and adherence
• Nutritional contemplates diet and food choices along with health weight.
• Spiritual contemplates core values, identity and purpose.
• Psychological and Emotional contemplates mental state, coping and problem solving skills, stress management and decision making.
• Behavioural and intellectual contemplate thoughts and actions that have positive or negative effects on life.
• Occupational contemplates activities in which one is engaged, interests, skills, performance and satisfaction
• Financial contemplates planning and saving, cash and credit management along with risk management.

In this context, it needs to be kept in mind that Wellness as a goal does not exclude communities or nations to legitimately aspire for the same. Every community and nation has the inalienable right to aspire and attain wellness of all its members or citizens by collective action. Wellness is Health in all dimensions. Wellness as a concept and goal is germane to the Health of an individual or society or a nation as a whole. The concept of wellness as expanded to a population and civilization involves the collective effort of the all stakeholders. Universal access to Health including safe water, sanitation, nutrition, primary education as well as eradication of poverty is the cornerstone in the path to wellness of a society and nation. There can never be wellness in the absence of Health. Inclusive and quality Healthcare delivery systems are a pre-requisite for any civilization to attain wellness for all its people independent of any differentiation or demarcation of any type.

Attainment of this larger context of Wellness mandates a political system to be founded on the principle of a social contract where ensuring access to fundamental public (basic) goods-clean air, safe water, sanitation, hygiene, nutritious food and basic health care and ensuring security to vulnerable populations from health expenditure shocks are visualized as its primary obligations and not options. This by itself goes to conceptualization of the cardinal principle of invocation and ushering in of ‘Welfare State’ contemplated as a goal for India in its Constitution guaranteeing all its citizens Liberty, Equality, Fraternity and Justice and reflecting them appropriately as accruable ‘Fundamental Rights’ to all its citizens and also providing for statutory grievance handling mechanisms for any infringement thereto of any type. The directive principles for the state policy further contemplated in the said Constitution bring out a desired path for a genuine wellness of all its citizens in the context of the core concept of the Welfare State as a set out goal for attainment.

Poverty has to be defined in all its multi-dimensional aspects not in terms of an income level alone. Poverty is a state of  being which induces low self-esteem and when combined with illiteracy, hunger and sickness becomes a morass from which it is almost impossible to pull oneself out.(2)

The Sustainable Development Goals (SDGs),(3) otherwise known as the Global Goals, are a universal call to action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity. Ending poverty and other deprivations must go hand-in-hand with strategies that improve health and education, reduce inequality, and spur economic growth.

The social determinants of health are the economic and social conditions that influence individual and group differences in health status. The World Health Organization says, “This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies, unfair economic arrangements (where the already well-off and healthy become even richer and the poor who are already more likely to be ill become even poorer), and bad politics.”

The United States Centers for Disease Control defines social determinants of health as “life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education, and health care, whose distribution across populations effectively determines length and quality of life. Social determinants of health do not exist in a vacuum. Their quality and availability to the population are usually a result of public policy decisions made by governing authorities.

The availability of quality, regulated childcare is an especially important policy option in support of early life. These are not issues that usually come under individual control but rather they are socially constructed conditions which require institutional responses. In this context, Health in All Policies has seen as a response to incorporate health and health equity into all public policies as means to foster synergy between sectors and ultimately promote health.

In view of the aforesaid cardinal considerations it is inevitably necessary to de-medicalize, democratize and decentralize health care delivery by having a wider group of people to share the powers, responsibilities, functions and a part of the financial burden. Such restructuring of the existing delivery systems, public and private, would need to be based on universally accepted set of core values, such as compassion, concern for the strict adherence to ethical norms and an unflinching commitment to patients’ well-being, and total adherence to the following guiding principles: (1)

• Being accountable to the health and well-being of the community it serves;
• Being responsible to the patient who receives treatment and care in dignity, fairness, without discrimination and in consonance with the basic tenets of a patients charter;
• Being accessible at all times and at all facilities — that is, none being denied care on grounds of time, distance or place of residence;
• Being adaptable to ensure that local practices, traditions and preferences are given due consideration;
• Being participatory — providing leadership in bringing about behaviour change for adoption of healthy lifestyles and practices that promote well-being and good health values; and
• Recognizing the special value of mothers, children and senior citizens in society.

However, in spite of all these ideal connotations and guiding principles the material factual reality is that Wellness has remained a concept and an idea even today. The same has been deemed as an ‘ideal state of life’ and a desirable attainment for an individual. This by itself is taken by many to be imaginary, farfetched, difficult to achieve and accomplish and therefore, is viewed to be a day dreaming which is more of a fiction than reality. As such, it is therefore, taken as a utopia.

It is in this stark backdrop, I with all humility intend to venture to propose that in the interest of men and mankind the concept of wellness accruable to all the Global citizens is a minimum must, which cannot wait any further and hence is required to be achieved sooner than later.

It is for this actualization it is mandatory that the path to wellness of a society or a nation should be tangible and defined. When we upscale wellness from a state of mental, physical and social well-being of an individual to a society or its people, it would require to be structured as clinical services, public health services with diligent cognizance of social determinants of health and extension of spiritual health as an inevitable dimension added thereto.

Conceptualizing good Governance to attain wellness of a people could mean clubbing together of these services (clinical, public health and social determinants) under one roof for which the prudent move would be to create a separate independent Ministry as Ministry for Wellness. The focused aim for the said Ministry would not only be the invocation of wellness for all but also ensuring its outcome measurement in the form of measurable happiness index as a parameter for the same.

Though this appears to be a simple idea, in effect this can genuinely revolutionize the Health of the Human race. In my opinion at least water, sanitation and poverty alleviation should be clubbed with Health for attainment of wellness of all the people in the society.

Idea and concept of wellness in philosophical terms applying to an individual would remain a mirage if the same could not be translated into actionable and measurable indicators of Health and Wellness. Path to wellness cannot be an unattainable rainbow. Rather it should be grounded in reality on Health and well-being of all with justice and equity without which it would end up in everything turning out to be a lip sympathy and a theatrical farce being played to the gallery.

I would like to conclude by recalling the inspirational message given by the famous legendary philosopher of India Swami Vivekanand, who said that “arise, awake and stop not till the goal is achieved’.

Let this dictum drive us all to alter the face of men and mankind in the name of humanity.”