for HIV/AIDS are effective and should be disseminated widely.”4

Although some drug treatments (such as AZT) have been developed that greatly slow the progression of HIV to AIDS, compliance with these treatments by HIV-infected individuals is often remarkably poor given what is at stake. In fact, across a wide variety of chronic and life-threatening diseases, from asthma and hypertension to epilepsy and renal disease, compliance with prescribed medical regimens is universally acknowledged to be a central problem for health care professionals. According to some analyses, as many as 50 percent or more of patients take prescribed medicines improperly—if they take them at all. The situation is just as bad, if not worse, for compliance with such disease prevention regimes as diet and exercise. The problem of compliance underscores the fact that developing a pill is only one step toward effective treatment or prevention. We must also get patients to take their pills: This is a behavioral problem that must be addressed at the individual and sociocultural levels of analysis.

It is now understood that stress (including job stress and burnout) and negative emotionality are important risk factors for disease, while social support and positive emotionality are significant factors in reducing both morbidity and mortality. While the bacterium h. pylori is found in the intestinal tracts of most if not all individuals suffering from ulcers, not everyone infected with h. pylori gets an ulcer: According to one theory, stress levels make the difference between health and disease. Although some of the neuroendocrine and neuroimmunological mechanisms underlying “psychosomatic” relationships are becoming known, the fact remains that both stress and social support are properly defined in psychosocial rather than physiological terms. Certain environments are more stressful than others, and in the final analysis it is the individual's mental representation of these environments that arouses stress. Although biological interventions may be able to alter the body's response to stress, the key(s) to alleviating stress itself will be found at the individual and social levels.

The psychosocial aspects of health encompass not just health and disease but a wide variety of health behaviors, broadly defined. The maintenance of health and the prevention of disease require individuals to engage in healthy behaviors, consult health care professionals when they experience the symptoms of disease, and participate actively in both the treatment of acute illnesses and rehabilitation of chronic disease. Somatization disorder, and the inappropriate and expensive use of health services that it entails, remains one of the most vexing mental health problems encountered in primary care and general hospital practice. The adverse health consequences of tobacco use are best prevented by convincing people not to smoke in the first place. The prognosis of breast cancer is best with early detection through a program of regular self-examination and appropriate mammograms. Proper treatment of hypertension requires that an individual take prescribed drugs even though he or she will not experience any relief of subjective symptoms. Successful management of renal disease is not accomplished by transplant or dialysis alone: In either case the patient must also make significant lifestyle changes. Health behavior, illness behavior, the sick role, and rehabilitation are not matters of anatomy and physiology: They are matters of behavior, society, and culture. They require coordinated and integrated attack by behavioral and social scientists working across the disciplines— and especially by investigators whose approaches transcend the boundaries of the traditional disciplines.

We have seen radical changes in the organization of health care, including changes in the duties of established professions such as pharmacy; the proliferation of new professions (such as nurse practitioners and physician assistants) involved in primary care; the impact of third-party payments on the practice of medicine; the rise of evidence-based medicine and other aspects of “managed” care; the “carving up” of health care through disease management and other programs; the advertising of pharmaceuticals directly to patients; the increasing acceptance of dietary supplements, herbal remedies, and other alternatives to traditional medications; and the availability of vast amounts of medical information, of variable quality, over the Internet. The advent of managed care creates at least the appearance of conflict between the ethical responsibilities of doctors to their patients and their financial responsibilities to their families and their employers. Physicians, once largely private practitioners, are increasingly cast in the role of employees: They have even begun to unionize. Health care, once a matter of a private relationship between doctor and patient, practiced in private offices and hospital wards, is now an

4  

“Interventions to Prevent HIV Risk Behaviors.” NIH Consensus Development Program, vol. 15, no. 2, February 11-13, 1997. The full consensus statement is available at http://odp.od.nih.gov/consensus/cons/104/104.htm .



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