The Time Is Now for a Whole-Person Health Approach to Public Health

Figure 1.

Vivek H. Murthy, MD, MBA VADM, US Public Health Service

From 2020 to 2021, life expectancy at birth in the United States dropped from 77.0 to 76.1 years, the lowest level in more than 2 decades. ¹ This decrease was largely driven by the toll of the COVID-19 pandemic and unintentional injuries, including opioid overdose deaths. ¹ The most dramatic drop was among non-Hispanic American Indian/Alaska Native (AI/AN) people at 1.9 years; in 2021, AI/AN people had a life expectancy at birth of 65.2 years, the same life expectancy as the total US population in 1944. ¹ The lower life expectancy overall and widening health disparities by race and geography made clear what many public health officials and researchers have reckoned with for quite some time: that the focus on treating disease once it is already apparent, which largely characterizes the US approach, cannot effectively address the major public health challenges of our time. It is becoming increasingly clear that a poor diet, sedentary lifestyle, chronic stress, and poor sleep can lead to multiple and often co-occurring diseases, such as diabetes, cardiovascular disease, degenerative joint disease, and depression, and that when addressed early, progression to disease can be prevented and health can be restored. ² Furthermore, understanding connections across biological, behavioral, social, and environmental domains can inform the development of multicomponent behavioral and/or systems-level interventions to prevent disease and restore health. ² We need a shift in perspective to an upstream “whole-person health” approach (also referred to as whole health or whole person) aimed at providing the tools and resources that individuals and communities need to face today’s challenges before they develop downstream consequences.

Whole-person health can be defined as “an approach that considers multiple dimensions of the patient and their context, including biological, psychological, social, and possibly spiritual and ecological factors, and addresses these in an integrated fashion that keeps sight of the whole.” ³ This whole-person approach must address the impact of structural and social determinants of health within existing public health and community-based health efforts to ultimately succeed. It must also become a cornerstone of how we improve the public health of communities and our country.

Fortunately, there are many innovative programs based on this principle that we can look to as we shift our approach to long-standing public health challenges.

Whole Health in the Veterans Health Administration

One example of a whole-person innovation with demonstrated results is happening at the US Department of Veterans Affairs (VA), the nation’s largest integrated health care system. The VA serves 9 million veterans each year across nearly 1300 health care facilities. ⁴ The VA Whole Health program was initially deployed at 18 flagship sites across the country that were part of the mandate in the Comprehensive Addiction Recovery Act to expand access for veterans to complementary, integrative, whole-health approaches, and it is rapidly spreading across the entire VA health system. ⁵

One goal of the VA program is to change the conversation from “What’s the matter with you?” to “What matters to you?” Because of the focus on the whole person rather than a specific disease condition, the conversation incorporates a public health lens to guide interventions addressing the structural determinants of care, which may hold people back from achieving what matters to them, whether that be food insecurity, gender- or race-based discrimination, or lack of safe housing in the community. This “person or partner” in care as opposed to patient perspective is especially important for veterans with complex conditions, such as chronic pain and mental health challenges, where a disease-focused strategy might not be as effective.

The whole-health approach integrates peer-led personalized health planning, use of whole-health coaches, and well-being classes with approaches that are allopathic (conventional medicine) and complementary and health based (eg, stress reduction, yoga, tai chi, mindfulness, nutrition, acupuncture) to focus on veterans’ goals, including education, housing, and financial needs.

One example of success is the Promoting Resilience and Equity With Whole Health Initiative at VA New Jersey. Through this initiative, health workers use a population health tool developed by VA called the Primary Care Equity Dashboard to identify racial and ethnic minority veterans with poorly controlled diabetes. Using scripts for consistency, members of the Whole Health team contact and invite these veterans to engage in a whole-health approach to manage their diabetes, including health coaching, mindfulness training, and nutrition education. In conjunction with didactics, awareness building, and skills development, individuals are given coaching to focus on their MAP (mission, aspiration, and purpose) and to understand that they can be in control of their health goals, which impact their life goals and quality of life. Veterans in the program have experienced improved diabetes control, in addition to improvements in quality of life, diabetes-related stress, and self-efficacy, and the program is now beginning its third cohort. In the words of one participant, “it used to be that my diabetes controlled me. Now I control my diabetes.” ⁶

Ongoing robust whole-health evaluation studies in the VA have demonstrated that this empowerment-focused, upstream approach is effective in addressing some of the most pressing problems facing the veteran community. The program has demonstrated a threefold reduction in opioid use among veterans with chronic pain who used whole-health services (38% decrease) as compared with those who did not (11% decrease). ⁵ Additional benefits have included increased engagement in health care and self-care, improvements in overall stress and well-being, and increased sense of meaning and purpose in life. ⁷ Increased meaning may be especially important because recent evidence shows that a loss of sense of purpose in life is associated with 2.4 times the risk of early mortality. ⁸

11th Street Family Health Services: A Center Focused on Health, Not Sickness

Another example of a community-based, whole-person approach to health is the 11th Street Family Health Services, a nurse-led federally qualified health center in Philadelphia, Pennsylvania. Starting in the 1990s in partnership with the Philadelphia Housing Authority, 11th Street nurses went out to listen to the community that they served, primarily in 4 housing projects, and asked residents what they thought the community needed. They started by visiting seniors at home to help them manage their health. They also helped create an emergency food pantry, and they lobbied the city to install a stop sign at a dangerous intersection in the neighborhood. In 1998, this effort grew into a free clinic in an empty public housing unit; in 2002, it grew into a full-scale health center guided by the voice of the community. According to Executive Director Roberta Waite, EdD, RN, “community members wanted some place where they could be healthy, not just a place to go when they were sick.” ⁹

Most of 11th Street’s 6000 patients live in local public housing and 85% are African American. Roughly 90% receive services through 11th Street beyond health care as it is traditionally defined: educational or job training programs, developing budgets with a social worker, or free legal services on housing or other issues. Through a partnership with the Farm to Families Initiative, eligible families receive weekly deliveries of fruit and vegetables, and regular cooking demonstrations are available to encourage community members to think about their eating habits in a new way. ⁹ The primary care teams, led by nurse practitioners, are multidisciplinary and include registered nurses, medical assistants, social workers, behavioral health consultants, and a nutritionist.

Evidence indicates that this model of care effectively addresses some of the most important public health challenges faced by the 11th Street community. ⁹ The center exceeds the national average for federally qualified health centers on many measures, including documenting patients’ body mass index, offering plans to help them achieve healthy weight (83% of patients vs 64% nationally), and achieving adequate control of hemoglobin A1c in people with diabetes (75% of patients vs 66% nationally). ⁹ When the health center found that just 31% of 11th Street children (vs 40% of children nationally) had received recommended vaccinations by age 2 years, the center developed a strategic initiative to increase timely childhood vaccination that included close tracking and follow-up. The initiative led to a 10% increase in immunization rates and recognition from the Philadelphia Department of Public Health. ⁹

These whole-person community-based investments have made 11th Street a national model for success, and this approach was endorsed by the National Academies of Sciences, Engineering, and Medicine in a recent report. ¹⁰

Making Room for Everyone’s Voice: The Talking Circle Intervention

The Talking Circle Intervention shows how culturally relevant programs can empower individuals and simultaneously tackle some of our most challenging public health problems. The Talking Circle Intervention is a culturally adapted version of the standard school-based alcohol and drug education program designed to support AI/AN young people. ¹¹ A deeply held belief among many AI/AN and Indigenous people is that a group is essential to a healing transformation, every member of the group is critical to the success of that group, and every member is valued equally. This sense of community and belonging is unfortunately absent for many young people in the United States today, with rates of loneliness, depression, anxiety, and substance use among young adults increasing in recent years and worsening in the setting of the COVID-19 pandemic.^12,13 A “talking circle” comes from the traditions of Indigenous people of North America and is a place where stories can be shared in a nonjudgmental and respectful manner and where a sense of belonging and community can be fostered.

Through a talking circle, individuals receive support and insight to confront challenges such as substance abuse, stress, and well-being. This long-standing tradition helps everyone in the group give voice to topics one might not otherwise talk about, and young participants are able to lean on one another and learn from one another’s experiences in ways that protect against the pull toward unhealthy and risky behaviors.

Talking Circle Interventions have demonstrated decreases in substance use behaviors, depression, and behavioral difficulties among participants in some studies. A study of 75 Native American participants aged 18 to 24 years that compared 6-month postintervention measures with baseline preintervention measures showed significant declines in substance use interest, stress, behavioral health issues, and cumulative trauma and an increase in a cultural identity measure of Native Reliance (a cultural framework that influences health and encompasses the holistic worldview of Native Americans). ¹⁴ Similarly, when compared with standard health education programs, incorporating the talking circle into after-school programs has been shown to more effectively increase self-reliance, cultural identity, health knowledge, and health behaviors, including improvements in obesity knowledge and behavior among young people in the intervention group versus the control group. ¹⁵ After adapting and testing the intervention for virtual use through video conferencing, the Virtual Talking Circle Intervention is now being implemented in multiple AI/AN communities across the United States. ¹⁶

Whole Health Is Public Health

Despite advances in treating disease during the past decades, many serious public health challenges endure, including the epidemics of obesity, substance use, suicide, depression, and loneliness. But we can make change happen. Public health departments, health systems, and community-based organizations can work together using a whole-person health approach to address these challenges in a way that is upstream, supportive, and empowering for individuals and communities alike. One example is the Robert Wood Johnson Foundation’s “Culture of Health” movement, which seeks to leverage current resources, encourage innovative partnerships, and empower individuals to make healthy choices in a more equitable environment. ¹¹ Partners and government stakeholders should leverage existing resources to drive further research as well. For example, the National Center for Complementary and Integrative Health at the National Institutes of Health is advancing research on whole-person health to drive a paradigm shift in health research. ²

Ultimately, a whole-person health approach is a public health approach. It considers the multiple dimensions and context of every individual and intensifies our focus on the social and structural determinants of health in a way that is empowering. The responses to the central question asked in whole-person health, “What matters to you?”, should inform public health policy and practice at the individual, family, and community levels. What matters to the health and well-being of individuals across our country must inspire us to invest in resources, align leadership, shift structures, and direct systems and services to meet these fundamental needs. We must do so in a way that not only responds to moments of disease or crisis but empowers individuals and communities and strengthens our collective prevention efforts.