WHAT IS MEDICINE?

Shah Yasin
Phua Lai Kit

www.monash.edu.my

WHAT IS MEDICINE?

Objectives

Know that modern “medicine” is much more than the diagnosis,
treatment and management of disease and disability

Know that besides pathogens such as bacteria and viruses,

sickness, disability and death can also be influenced by
behavioural, environmental and socio-economic factors

Appreciate that doctors and other health care professionals need

to take all these other factors into account in order to treat or take
care of patients successfully

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 WHAT IS MEDICINE?

What are you here to learn?

What causes disease?

What causes people to fall sick?

Prevention or Cure: Which is more important?

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Some Interesting Facts

1) Women live longer than men

Life Expectancy at Birth (years)

Male Female
Malaysia 71 75
Australia 76 81.6

Healthy Life Expectancy at Birth (years)

Malaysia 59.7 63.4

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 Some Interesting Facts
1) Married men live longer than unmarried men
2) Married women die faster than unmarried women

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Some Interesting Facts

1) Women are more likely to suffer from long term
activity limitation
2) Women are more likely to suffer from chronic
conditions like osteoporosis, arthritis and migraine
headache

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 Some Interesting Facts

Lower income people die earlier than those with

high incomes
Less educated die earlier than the better educated

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More Facts
In the young, psychological health needs attention:
In the middle aged to senior, physical health needs
attention
Young people are more psychological unwell
compared to older people
Physical Health Psychological
Health
Young high low
Senior medium/low medium/low

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 Theory of Well Being
Social & Environmental Well being

Mental Well being

Physical Well being

Our physical health is intimately related to
our mental health which is intimately
related to the social and environmental
status

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Socioeconomic & Environmental

factors (Income/education)

disease & death

Psychological factors Physical Illness

(depression/anxiety (Diseases like diabetes)
social support)

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 What does social and environmental well
being mean?

Two areas:
- Employment environment
- Family environment

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Working Conditions
Two areas:
- Job satisfaction
- Work stress

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 Social Environment

Emotional support
is from social network e.g. close
friends, family members

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Social Environment

Good Social network

Safety, Caring & Respectful environment

Fosters a Sense of Well being

Acts as a buffer against health problems

(such a network may be as important as smoking, high
blood pressure for your well being)

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 Mental Well being

 Anxiety
 Depression

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Three Questions

 Are psychological factors associated with

heart disease
 Are psychological factors related
aetiologically to heart disease
 Clinical significance of this relation

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Major Psychosocial Factors

 Depression
 Anxiety
 Personality and Character traits
 Social Isolation
 Chronic and Sub-active life stress

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Historical Perspective

By 1970s evidence of some sort of association

between psychological and social factors and
mortality and morbidity was accumulating
Social factors
Psychological factors

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Social Support

 Prospective Community Based Studies

 Social network = presence of family
affiliations, number of friends, participation
in group activities

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Relative Risk

Risk of CVD in the in

the group with the
condition
Relative risk =
Risk of CVD in the
group without the
condition

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Relative Risk of CVD for Small Social Network

Risk of CVD in the in the

group with Small Social
Relative Network
= = 2-3
risk
Risk of CVD in the group
without Normal Social
Network
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Social Support

Low levels of perceived emotional support

RR for CVD 2 – 3 (among healthy)

RR for CVD 3 – 5 (existing CV illness)

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 Socioeconomic Status

Low SE status = increased CVD risk

Whether SE status measured by income,
education, occupation.
1. Gradient effect
2. Low SE status associated with:
 High risk behaviours
 Psychological risk factors

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The Holmes-Rahe Scale

Life Events
Death of spouse 100
Divorce 73
Martial separation 65
Jail term 63
Death of close family member 63
Personal injury or illness 53
Marriage 50
Fired at work 47
Marital reconciliation 45
Retirement 45
Change in health of a family member 44
Pregnancy 40
Sex Difficulties 39
Gain of new family member 39
Business readjustment 39

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 Studies of Social Network and Social Support and CAD
Hemingway,Marmot: BMJ 1999;318:1460-1467 ( 29 May )

Author, year, country Sam Exposure RR Summ

Medalie 1976w49 Israel 10 000 Perceived love/support from spouse 1.8 +
House 1982w50 USA 2754 Social relation/ activities N/A +
Berkman 1983w51 USA 4725 Social network index 2.13 ++
Reed 1983w52 USA 4653 Social network score N/A 0
Kaplan 1988w53 Finland 13301 Social network index 1.34 0
Vogt 1992w54 USA 2603 Network scope, freq, size 1.5 +
Orth-Gomer 1993w55 Swe 736 Emotional support 3.8 ++
Kawachi 1996w56 USA 36 624 Social network index 1.14 0
Chandra 1983w57 USA 1401 Marital status Impr +
Ruberman 1984w58 USA 2320 Social support, life stress 4.5 ++
Wiklund 1988w59 Sweden 201 Social support, depression Incr (s) +
Case 1992w60 USA 1234 Living alone, disrupted marriage 1.54 +
Hedblad 199261 Sweden 98 Social support/ network 5.6 ++
Williams 1992w62 USA 1368 Structural social support (marital status) and function 3.34 ++
social support
Berkman 1992w63 USA 194 Emotional support 2.9 +
Gorkin 1993w64 USA 1322 Social support 1.46 +
Jenkinson 1993w19 UK 1376 Social isolation, life stress, depression, type A 1.33 0
Friedman 1995w65 USA 369 Social support, life events, depression, anxiety, type A, Not +
anger stated

% Experiencing End Point From Least to Most Socially Supportive Division (1=least supportive)
Social Support and Clinical Outcome: Evidence of a Gradient Effect

Variable
Assessed End Point Subjects No. of
(Reference) Divisions 1 2 3 4 5 6

Emotional support Death Men (n=100)2 3 59 41 23 N/A N/A N/A

(119)

Women 3 43 32 22 N/A N/A N/A

(n=94)2

Social integration 6-year CAD All patients 3 5.7 4.5 1.5 N/A N/A N/A
(100) incidence (n=749)

Social network (98) Death Men (n=2229) 4 16 12 9 6 N/A N/A

Women 4 12 7 5 4 N/A N/A

(n=2496)

Social activity Death Men, 1913 5 28 19 15 11 6 N/A

score (103) (n=787)

Men, 1923 5 14 9 7 5 3 N/A

(n=292)

Social relationships Death Men (n=1251) 6 30 24 12 11 11 8

(101)

Women 6 7 10 9 5 6 3
(n=1284)

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 Studies of depression and anxiety and coronary heart disease

Author, year, country sample Exposure Follow up RR Summary

Hallstrom1986w20 Sweden 795 Depression 12 5.4 ++
Hagman 1987w21 Sweden 5735 Anxiety 2-7 Angina +
Haines 1987w22 UK 1457 Phobic anx 10 3.77 ++
Appels 1990w23 Neth 3877 Depression 4.2 1.86 +
Anda 1993w24 USA 2832 Depression 12 1.6 +
Aromaa 1994w25 Finland 5355 Depression 6.6 3.36 ++
Kawachi 1994w26 USA 33999 Phobic anx 2 3.01 ++
Everson 1996w27 Finland 2428 Hopelessness 6 2.05 ++
Wassertheil-Sm1996 USA 4367 Depression 4.5 1.18 +
Barefoot 1996w29 Denmark 730 Depression 27 1.7 +
Kubzansky 1997w30 USA 1759 Worry 20 1.23 +
Ahern 199031 USA 353 Depr/Anx 12 1.3 +
Kop 199432 Netherlands 127 Ehaustion 1.5 2.34 +
Ladwig 199433 Germany 377 Depression 0.5 2.31 ++
Frasure-Smith 1995 USA 222 Depression 1.5 6.64 ++
Barefoot 1996w35 USA 1250 Depression 19.4 1.66, +
1.84 1.72
Denollet 1996w36 Belgium 303 Dpression, 7.9 2.7 ++

Long-term survival after MI in relation to Beck

Depression Inventory Score during hospitalization

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Summary of Evidence (I)

In Healthy People studies suggest an aetiological

role for
Type A/hostility (6/14 studies),
Depression and anxiety (11/11 studies),
Social support (5/8 studies)

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Conclusions and Questions?

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