Grace is 73 years old, retired, and living with her husband and a small dog of questionable lineage in a three-bedroom suburban house. Together, Grace and her husband manage a substantial garden, using largely organic practices and yielding an impressive array of flowers, as well as fruits and vegetables that are cooked, canned, frozen, and distributed to friends and family. Over the last several years, Grace has transformed the family recipe archives to conform to a low-fat, low-sodium diet--not an insignificant transformation for a cuisine developed in Eastern Europe and the North Dakota prairie.

Grace maintains contact with her three adult children, serving as the central node in a complex communication network linking myriad aunts, uncles, and cousins on two continents. Her table is the center of weekly visits with her children and their spouses and is the festival board on holidays. She and her husband often care for their four-year-old grandson, either in their home or in their son's, where the tasks include caring for a barn full of animals.

Every week, Grace attends church, volunteers at a foodshelf, plays cards with friends and reads a book or two. She walks two to three miles each day, usually along a creek near her home, where she keeps track of the flora and fauna as they change with the seasons. She is an unreconstructed liberal with an active interest in both politics and social issues.

Grace is generally healthy, though she has osteoporosis and arthritis which occasionally limit her movement. She sees a doctor when necessary and takes a variety of prescription and over-the-counter medications as well as vitamins, minerals, and herbal supplements.

That she has come to this point in her life with a keen mind, an able body, and a zest for living is tribute not to a cadre of doctors, hospitals, and pharmaceuticals. Rather, her health is a function of how she lives her life and the decisions she makes on a daily basis about what to eat, when to exercise, and when some symptom or other requires more expertise than she and her immediate circle can bring to bear. It is also a function of many unnoticed events and processes that keep her connected and interested in what's going on around her.

If we were to ask an expert in healthcare systems to identify the health resources that Grace uses, the answer would be limited to her occasional visit to the doctor and the medications she takes. But there is little accuracy in saying that these relatively unimportant events define what she does about her health. Moreover, it is unlikely that Grace would describe her visit to the doctor as an encounter with the "healthcare delivery system" any more than she would describe her grocery shopping as an encounter with the "agribusiness sector." In both cases, she is merely living her life. The grocery shopping is just part of how she prepares food for herself, her family, and her guests, and the visit to the doctor is just part (and a small part, at that) of how she manages her health. Limiting our understanding of how this woman pursues her health to only those encounters she has with what we hold to be the "healthcare delivery system" impoverishes our learning and dramatically limits our ability to foster health.

This article focuses on a different way of thinking about health care, and on some of the implications for how and where our society invests in health resources. It offers a far more powerful view of how Grace stays healthy, and it suggests important steps we should be taking as a society to improve the resources available to us.

FROM ONE TO MANY
Pathologists use the term idiopathic to describe a disease with an unknown origin. Literally, the term refers to a condition that is personal and distinct, and arises from within oneself. Increasingly, it has relevance to the ways in which each of us cares for our health--that is, we each have our own "health system," comprising a unique array of personal and public resources, connected in idiosyncratic patterns, and oriented to goals that are our own.

The notion of idiopathic health systems contrasts dramatically with the concept of a monolithic healthcare delivery system as a way of thinking about health resources. That each of us builds and manages (however imperfectly) our own healthcare delivery system flies in the face of the behavior and pronouncements of those individuals and institutions that are part of the monolith--hospitals, doctors, nurses, insurance companies, pharmaceutical companies, and government agencies, among others. But the concept will be readily understood by anyone who has a chronic health condition (for example, diabetes, arthritis, asthma, or high blood pressure). Faced with the realities of managing their health with the occasional assistance of a "healthcare delivery system" fixated on acute conditions such as infections and broken bones, people with chronic conditions develop highly individualized "health systems."

When we talk about "healthcare reform" or "managed care" or "healthcare professionals," the set of resources we are considering may be important as economic entities, but they represent only a fraction of the resources that people include in the systems they use to manage their health. And, for the vast number of Americans with chronic health conditions, the importance of that limited set of resources is small indeed. Grace has changed doctors a number of times in the last few years--not because she wanted to, but because the vagaries of insurance coverage required it. But these changes have had very little effect on her health, because her health is far less a function of what the doctors do and far more a function of what she does.

In his work on learning organizations, Peter Senge emphasizes the importance of humility--the notion that "any model is an operational simplification, always ready for improvement." He notes that humility allows us to take a more compassionate and empathic stance and to recognize that the actions of others, which we may neither condone nor understand, arise from viewpoints that are, in some sense, as valid as our own. Without that humility, Senge says, we become ever more narrow in our beliefs and understanding and cut ourselves off from the learning necessary to advance. To have the humility essential to truly understanding how to foster health, we must begin to view the resources commanded in the "healthcare delivery system" as merely part of individually determined and managed health systems and of varying importance and value across individuals, families, and communities.

DISTINCTIONS
Possibly the most fundamental of the distinctions arising from this approach is the healthcare delivery system's view of health as an end, in contrast to the consumer's perspective of health as a means to some other end. That end is individually determined and, probably quite often, implicit. It may be as robust as "life, liberty, and the pursuit of happiness," as limited as living through this day, or as mundane as walking to the bathroom. The point is that, whatever the end in view, health care is only one of the many resources necessary to that end, and the consumer may well perceive it as the most important of them.

A second distinction can be seen in how people are viewed. The healthcare delivery system tends to see health professionals, institutions, and technology as critical health resources and, therefore, sees "patients" as "consumers." The idiopathic perspective sees individuals and families as builders and managers of complex health resource systems, only one component of which is health professionals, institutions, and technology.

How the use of health resources is viewed is another distinction. Steps taken by a person with a chronic health condition are regarded as "health behaviors" by providers, and the degree to which those behaviors reflect the instructions of the provider yield a measure of the patient's compliance with the doctor's orders. Yet the person with a chronic condition is not likely to segment those behaviors from the rest of the daily or weekly activities in which he or she engages. That is, what the physician sees as compliance or non-compliance, the person with the condition sees as life. As a result, deviations from ideal compliance (as measured by the physician) may be merely individualization of rather generic instructions.

The nature of evidence yields another distinction. Medical science takes pride in its reliance on empirical data. The result is a persistent belief in the healthcare delivery system that data underlie much of what is done and achieved. There is also the insistence that other "complementary" or "alternative" therapies substantiate their worth by producing valid data. In contrast, consumers' decisions about what to incorporate in their idiopathic healthcare systems may include reference to data, stories and anecdotes, intuition, superstition, faith, and other bases of belief and knowledge. Clearly, the reliance on data is important to the performance of the healthcare delivery system, but it is unlikely that individuals and families will abandon the other ways that they have developed for knowing what works for them.

This difference in approaches to evidence helps explain consumers' use of resources that are variously regarded with indifference, disbelief, derision, or hostility by mainline Western medicine providers. It may be instructive to contemplate that the lack of standing of these other therapies among mainline providers is largely irrelevant to people who use those therapies. Indeed, they use them because of their perceived (or hoped for) efficacy; the inability of mainline providers to characterize how and why these therapies "work" has little meaning for many consumers. That patients seldom report the use of these other therapies to their medical doctors reinforces this distinction.

The value placed on learning is another area of distinction between these two perspectives. The healthcare delivery system devotes enormous resources to the initial and continuing education of its practitioners. In contrast, the resources it devotes to the its patients's education is nil. In idiopathic health systems, the education accomplished by health professionals remains important, but the learning of individuals and families becomes fundamental. Because most of the decisions critical to the health of people are made by those people or by their families, we need to become far more aware of how they learn. The view that patients are passive recipients of care does not require--indeed, almost always abjures--critical and systematic thinking by those patients. In idiopathic health systems, facilitating systematic, individualized, culturally competent, family- and community-based learning becomes the central goal of most health resources.

The notion that there is, in some palpable form, a "healthcare delivery system" arises in another distinction. Those of us who ponder the vagaries of healthcare delivery and/or the evolution of health policy have coined this term to refer to what we believe is the set of resources that "provide health care" to people. But, from the standpoint of idiopathic systems, such a system does not exist. At most, the "healthcare delivery system" of our writings and conversations is the set of relationships among some segment of the resources that many people include in their idiopathic systems. Admittedly, most of these idiopathic systems include a substantial set of common elements--primary care physicians, local hospitals, the local public health establishment, prescription and over-the-counter pharmaceuticals, and the community's emergency services, among others. But the other resources that are included in these systems are both substantial and highly individualized, to the point that trying to understand the real dynamics of health from the standpoint of the "healthcare delivery system" is futile.

If the idiopathic way of thinking about health resources has merit, then a number of implications follow. Several of these are discussed briefly below.

WHAT DOES THE INDIVIUATION OF OUTCOME MEAN FOR QUALITY MANAGEMENT?
In a 1992 editorial in the Harvard Business Review, Rosabeth Moss Kanter used baking soda to illustrate how "products derive their meaning and value only from the uses to which customers put them." Arm and Hammer produces baking soda, but consumers see it variously as a baking ingredient, a dentifrice, a refrigerator deodorizer, a cleaning compound, a pharmaceutical to combat itching, and myriad other things. The value of baking soda cannot be limited to any one of these functions and must be assigned by the consumer at the time of use. So, too, must the value of the goods and services produced by the healthcare industry be judged by the consumer in the context of that consumer's use of them--that is, in the context of the idiopathic system of resources that the consumer uses to manage his or her health.

It is worth noting that Arm and Hammer has begun to capitalize in the many ways in which its product is used by consumers. Thus, supermarket shelves now hold chewing gum, toothpaste, underarm deodorant, carpet cleaner, cat litter deodorizer, dishwasher detergent, laundry soap, and room deodorizer all bearing the Arm and Hammer brand. In contrast, with the exception of sports medicine, some obstetrics, and a very few chronic disease centers, the healthcare delivery system is still producing baking soda: care that is largely undifferentiated by the outcomes that consumers seek.

Consider, in this context, the current interest in assessing the outcomes of healthcare procedures and comparing the value of various procedures on the basis of these outcomes. From the perspective of idiopathic health systems, the systematic measuring of healthcare outcomes makes sense if it is recognized that the procedures in question have value only as they contribute to the outcomes valued by the consumers of the product or service. However, health outcomes measurement almost always occurs relative to abstract standards established by providers or insurers. Thus, hospitals measure the success of surgical procedures on the basis of required days of hospitalization, subsequent incidence of infection, or cost. Consumers are likely to judge the success of a surgical procedure far more individually and relative to their lives. Consumers are likely to be interested in how the procedure will affect their ability to work, play golf, shop for groceries, or visit their son in Colorado.

If a healthcare provider organization is to manage the quality of the service it produces, it is not sufficient for it to measure that quality against some abstract and generic standard. Clearly, those standards remain important--no one wants to have surgery in an operating room that has not been sanitized in whatever ways are most scientifically sound at the moment--but they are not enough. In addition to those standards, the provider interested in maximizing quality (in "meeting and exceeding the expectations of the customer") will want to know how the service is used in the various idiopathic systems of which it is a part and what the results of its uses are, relative to the goals of the recipients. In short, people in the community are not particularly interested in the hospital's infection rate. What they want to know is how the operation will affect their ability to live their lives.

Consider also how difficult it is for American healthcare providers to customize their products. Maybe in an earlier time when doctors made house calls, they could understand enough about the complex parameters of their patients' lives of to tailor their remedies and recommendations to those parameters. But in today's world, where the office visit rarely exceeds 10 minutes and where chartings and test results from three other specialists must be considered, what can the doctor know about variables of critical import to the patient and his or her use of the pills or advice that are to be dispensed? Isn't it important for the doctor to understand what the patient believes about health and healing, what other healing philosophies the patient is accessing (and typically not disclosing to the doctor), who in the patient's family is involved in daily decisions about the patient's health, how the patient handles stress, what he or she eats, and the myriad other differences that make this person an individual and a member of a family and a community quite distinct from those of the doctor?

WHAT CONSTITUTES INFORMED DECISION MAKING?
Addressing questions about how individuals pursue their health would create a good deal of discomfort for American healthcare providers. among other things, they might recognize that in some ways it is possible to achieve success in the healthcare marketplace without having much influence on the health of people. Instead of pursuing such questions though, American providers have increasingly turned inward, becoming ever better at processes that are increasingly irrelevant to the lives of consumers.

Answering such questions would also place the service in question in the context of the idiopathic health system of the particular consumer. Understanding that context would encourage discussion between providers and consumers about important trade-offs. Those trade-offs include consideration of the monetary and human costs of various alternative therapies; the consequences of such therapies not only for the fragmentary health issue at hand but for the larger life of the consumer; options for pursuing a fuller life through other resources in the community (education, recreation, faith) besides or in addition to health care; or the consequence of side effects of treatment that can only be assessed by the consumer--for example, the effect of various forms of treatment on important relationships and on the ability to contribute to one's family or the community.

Much of this has to do with the sacrifice of self that has been integral to seeking help from the medical establishment during this century. Fifty years ago, the tremendous and evident contributions that medical science made to the lives of consumers may well have warranted how consumers were expected to behave: "take off your clothes, lie down, and do what you're told" makes a lot of sense when you are beset with an acute illness. Today, though, the odds are four to one that the condition that brings a consumer to the doctor's office or the hospital is a chronic condition, and submissive compliance is not the best medicine.

WHY IS THE PHYSICIAN-PATIENT RELATIONSHIP IMPORTANT?
Many factors raise questions about the validity of the notion that the patient-physician relationship is fundamental to health. These include the fact that almost everyone will use more than one physician at any point in his or her life, the inability of even the most dedicated primary care physician to grasp (much less manage) the tremendous array of resources in any of his or her patients' idiopathic systems, the terrible lack of coordination among providers and among information systems, and the lack of flexibility in most medical systems. The real responsibility and authority for health and health decisions must reside with the individual and the family, not in the connection with some segment of the resources it uses to pursue health.

Healthcare providers of every stripe--including those of the Western scientific medicine stripe--need to value the contribution that many resources make to the health of people and families in the community. There is no one right way to get healthy or stay healthy, and the evidence that supports one approach may not be the evidence that is valued in another. The true test is in the degree to which various resources are found useful by consumers, not by other providers.

WHAT ROLES MIGHT THE FAITH COMMUNITY HAVE IN HEALTH?
There are many levels of relationship between spirituality and health. At the most fundamental level, the meaning that spirituality adds to the lives of people has important bearing on their ability to be well and to cope with health issues. At another level, the beliefs we hold have a good deal to do with how we pursue health and how we relate to changes in our bodies. More directly, churches and other organized elements of the faith community become critical health resources for many people. For example, visitation programs, meal programs, and other elements commonly found in community churches have long been important to the lives of many senior citizens. Other churches develop support groups for their members with particular health issues or interests, facilitating the exchange of information and support among people with similar beliefs who are dealing with similar problems.

Expanding our understanding of what can be a health resource leads to a new appreciation of the value of the faith community in the lives of its members. The faith community plays a role in the larger community that can be no less important than that of the local hospital or clinic, especially because of its continuing presence and understanding of at least some of the important cultural variables affecting the health of its members.

As elements of their own geographic communities, organizations in the faith community also have the opportunity to support the health of those who live in that same community but who may not be aligned with the particular philosophy of that organization. This perspective underlies the traditional involvement of some churches in neighborhood organizations, foodshelves, and homeless shelters. As a community resource, churches and other institutions have much to offer their neighborhood: information and referral, meeting space, leadership, political connections and other resources, as well as programs more directly related to health, such as those noted above.

WHAT ARE THE ASSUMPTIONS UNDERLYING OUR HEALTHCARE SYSTEM?
Peter Drucker has developed the notion of the "theory of the business," a set of assumptions about what will lead to success. He argues that, while these assumptions are merely hypotheses to be tested in the company's performance, they underlie the founding of any business and are often assimilated into the company's culture without the rigors of testing. When that occurs, says Drucker, the "theory of the business becomes obsolete and then invalid." It is increasingly apparent that it is time to test the fundamental assumptions underlying the theory of the business of the American healthcare delivery system. To what extent do the following assumptions about American health care remain valid today?

• The system's customers are sick.
• The voice of the provider is the most important source of information for the consumer.
• Western scientific medicine is the gold standard in achieving health.
• Providers are capable of knowing how best to improve their services.
• The patient-physician relationship is critical to positive health outcomes.
• Larger, more complex, and more integrated systems are better.

WHAT MIGHT A NEW PERSPECTIVE MEAN FOR THE DESIGN OF HEALTH SYSTEMS?
If we are to maximize the return on our societal investments in health, we must be willing to consider investments in a much wider array of resources than we have in the past. We must also be willing to compare the "health return" on investments in new medical technology, more doctors, and more elaborate hospitals with the health return on investments in information technology, community education resources, better nutrition, enhanced exercise and recreation resources, and better transportation systems. If health derives from many resources in addition to those in the "healthcare delivery system," then we must consider those other resources as worthy candidates for our investments in health.

Convenience and orientation to the customer take on entirely new dimensions in this paradigm. Recognizing that the goods and services produced in the "healthcare delivery system" are always customized by consumers should foster enormous flexibility in providers. This flexibility should meet the obvious need for convenience in location and time of services, as well as include serious efforts to understand the cultural variables that influence how goods and services are used by the consumer.

We must learn much more about how the community can influence the health of its members. Many of the resources that are important to people's health reside not in the "healthcare delivery system" but in the community, a place that we know precious little about relative to health (at least in part because our learning about health has focused largely on the effects of the "healthcare delivery system"). Indeed, John McKnight (The Careless Society: Community and its Counterfeits, BasicBooks, 1995) argues that, by treating the health needs of consumers as a commodity, healthcare providers advance their market-based strategies while they weaken communities. Before we adopt a strategy that labels people according to needs that only professionals and institutions can (or are allowed to) address, we should ask whether there are ways to encourage and empower the community to address those same needs. Finally, despite this article's repeated reference to the concept of a market for health services, it is important to recognize that the idiopathic model includes both market and nonmarket forces. While many of the resources that people include in their idiopathic systems are market commodities, many others--of equal or greater importance, such as empathy, compassion, justice, wisdom and culture--do not reside in markets and are obtained in other ways. Opening our thinking about health to more than the resources that derive from markets allows us to consider the most important factors.

NOTES
1. This fixation persists despite the facts that nearly half of Americans have at least one chronic condition and at least 80 percent of this country's healthcare expenditures derive from chronic conditions.