The emergence of multimorbidity as a matter of concern

Multimorbidity, or the co-occurrence of two or more long-term health conditions in one person, is seen as one of the greatest challenges to contemporary healthcare services. As the WHO explains: “the ageing population, less healthy lifestyles and an increasing incidence of chronic conditions mean that multimorbidity is on the rise. This trend is a major health care challenge facing all countries across the world” (2016).

The WHO frames multimorbidity here according to a common narrative: rising life expectancy due to the combination of better hygiene and new biomedical techniques has led to a larger proportion of people living into older age with multiple, often age-related, chronic conditions. This suggests that multimorbidity is a new phenomenon, characteristic of our time—so much so that some researchers speak of a ‘multimorbidity epidemic’ (Adan et al. 2020).

However, these claims obscure the fact that multimorbidity is an ambiguous “matter of concern” (Latour 2004) for the scientific community. Despite the consensus that the prevalence of multimorbidity is rising, there is no consensus on how to measure multimorbidity. Across studies, the number of diseases included in the definition of multimorbidity might range from two to two hundred and eighty-five (Ho et al. 2021). This lack of consistency in definitions leads to widely diverging prevalence estimates, from 16% to 58% in UK studies for example (Hajat and Stein 2018). Aside from diverging indices, epidemiological estimates of the rising prevalence of multimorbidity often fail to consider how disease categories change over time. Changes in how certain diseases are defined are sometimes more responsible for apparent shifts in prevalence over time than actual changes in the prevalence of pathology within the population. For example, Campos and colleagues (2006) have argued that the ‘obesity epidemic’, rather than reflecting actual increased medical risk related to weight, is based foremost on moral panic around weight and stigmatising attitudes against minorities and socio-economically disadvantaged people.

The term ‘chronic illness’ upon which any definition of multimorbidity leans, is a relatively new term in health care. Similar to the explanatory framework applied to the rising prevalence of multimorbidity, the rise of interest in chronic illness is often attributed to a spectacular rise in life expectancy, due to improved control of infectious diseases in the 20th century. This narrative, however, ignores how from the 1950s onwards, conditions that were previously seen as the result of a ‘normal’ process of ageing and degeneration, such as arteriosclerosis and cardiovascular disorders, became pathologised and brought under medical control (Armstrong 2014). In the first half of the 20th century, causes of death such as ‘old age’, ‘senility’, and ‘atrophy’ were still common on death certificates; from the 70s onwards, almost no one is registered as dying of so-called natural causes.

In addition to this, diagnostic thresholds for disease categories have also broadened over time. In the U.S., for example, a decrease in the diagnostic threshold for hypertension in 2003 resulted in a 35% increase in the number of North Americans fulfilling the new diagnostic criteria (Martin et al. 2014). This process is sometimes referred to as ‘diagnostic creep’ (Moynihan 2016). The consequences of diagnostic creep are by no means trivial: more diagnoses lead to an increased burden of treatment and risks overdiagnosis and overtreatment. Moreover, by labelling more and more people as sick, the potential markets for those selling medicines are becoming bigger, while this trend is not matched by an increase in care infrastructures that can provide other forms of necessary support.

Our insistence on bringing nuance to claims of a ‘multimorbidity epidemic’ is by no means intended to deny “the real” of multimorbidity. It is clear from qualitative research that multimorbidity is a (multi-faceted) problem. Patients categorised as ‘multimorbid’ experience high burdens of treatment (Ørtenblad, Meillier, and Jønsson 2018), take too many medicines (Ecks 2021), and struggle to balance the demands placed on them by ‘the clinic’ with the demands of their ‘lives-as-lived’ (Fudge and Swinglehurst 2021). Health practitioners, on the other hand, also experience the management of patients with multimorbidity as “an endless cycle of problems” (O’Brien et al. 2011) and find evidence-based guidelines are inadequate for this patient group (Sinnott et al. 2013). In our recently-published critical review describing the emergence of multimorbidity as a matter of concern for the health community, we argue that it is not so much the rising prevalence of co-occurring long-term conditions that poses such a challenge, but rather the increased inability for contemporary health services to accommodate patients with multiple long-term health conditions (Blarikom, Fudge and Swinglehurst 2002).

What is driving this increased difficulty to manage multimorbidity in contemporary health care systems? First, there is the obvious problem that diagnostic categories are based on specific disease entities. This ‘single disease model’ is the foundation of biomedical health care. Most randomised control trials only include ‘ideal-type’ patients with single diseases, employing medicines that the pharmaceutical industry develops to act in a ‘disease-specific’ way. Likewise, treatment guidelines and protocols are typically based on single diseases. If ‘best practice’ treatment guidelines, developed for single diseases are simply added up for people with multiple conditions, high treatment burdens and overtreatment may be the unintentional and potentially harmful consequence.

Moreover, in the last few decades, medicine in the UK has become increasingly technical, specialised, and bureaucratised. For example, the Quality Outcomes Framework (QOF) was introduced in General Practice in 2004. The QOF is a pay-for-performance system through which GPs are financially rewarded for delivering certain interventions. This system inherently subscribes to a biomedical model in which therapeutic interventions are aimed toward single diseases rather than individuals. It places an economic value on patients’ biomarkers, which has been argued to commodify patients’ bodies and heighten the importance of information technology. Since the introduction of the QOF, certain chronic conditions have been steadily rising in prevalence in the UK. Hypertension is one example.

The logic of the QOF is a clear example of how care services become organised around a risk-based approach. Although the intention of diagnosing conditions that would otherwise potentially remain underdiagnosed is laudable, some caution is warranted here in terms of potentially over-diagnosing certain health conditions and labelling more people as “sick” who may not always benefit from that label. For example, no condition has risen so much in prevalence as depression in the UK since the introduction of the QOF. Given that people with chronic conditions may experience emotional distress associated with managing a demanding chronic disease there is a risk of blurring the boundaries between general malaise and psychopathology. As Danielle Carr recently stated in The New York Times: “a crisis that affects mental health is not the same thing as a crisis of mental health”.

All these factors together make it hard for contemporary British health care systems to accommodate people with multiple conditions. Moreover, the development of bureaucratised and cost-effective health care was accelerated by the global recession in 2008. Primary care systems in Europe and the UK experienced significant financial disinvestment, which has affected the poorest neighbourhoods the most. Perhaps this is reflected in the statistic that patients living in more deprived areas are prescribed more medicine than people in less deprived areas, even in contexts of similar rates of health consultations. In this way, health care services under financial pressure inadvertently contribute to the ‘medicalisation of poverty’, a process whereby more resources are spent to address healthcare needs brought on by poverty, for example through antidepressants, then to provide for the material needs of people living in socio-economic adversity.

This last point is especially important. Although it is difficult to compare the prevalence of multimorbidity across studies, due to the difference in definitions, we have learned a lot about the distribution of multimorbidity by comparing its prevalence within specific studies. In a study (Barnett et al. 2012) of a Scottish cohort of 1,7 million people, for example, the prevalence of multimorbidity, against expectations, was highest in working-age rather than older adults. Moreover, the onset of multimorbidity happened 10-15 years earlier in adults living in socio-economically deprived areas, and the combination of mental and physical illness was especially associated with socio-economic deprivation. The onset of multimorbidity must, therefore, be seen as the entanglement of physical, mental, and social vulnerabilities. An inability to recognise it as such is what leads to its mismanagement in health care.

The term ‘multimorbidity’ subsumes a wide range of people with different conditions. This makes it a hard phenomenon to grasp. One workaround is to limit the research focus to a few specific, commonly co-occurring diseases (as is done, for example, in Syndemics theory). A pitfall in this approach is that it assumes that people with the same conditions will have similar experiences that can be categorised into common patterns, which unintentionally reifies current disease categories. People with multiple conditions often experience symptoms that are hard to classify and suffer in part, because of the way diseases are currently categorised and treated. Moreover, the move to focus on some specific disease combinations robs multimorbidity of its nosological independence, while we would argue it has its worth as an object of research.

The conceptual strength of ‘multimorbidity’ resides exactly in its difficulty to be pinned down. As such, ‘multimorbidity’ takes our attention away from specific body parts and organs (or even collections of organs or ‘systems’). Instead, it draws our focus to how the body operates as a whole. We, therefore, propose a novel understanding of multimorbidity: not as something that exists as a unified phenomenon, in the bodies of people, but as an experience that manifests through the discrepancy between medical policy and life-as-lived, brought to the fore by people’s attempts to bridge fissured care systems.

Studying multimorbidity as an experience, in this sense, can move our attention away from attempts to pin down the concept through ever-more precise definitions and measurements, an endeavour that has cost much effort but has not returned many results over the past ten years. Instead of locating multimorbidity as a problem in a person’s body, we can instead think of it as an experience that exposes the limits of diagnostic categories and disease-based care. Studying multimorbidity as such can be achieved through a focus on daily life and people’s navigations through systems of care.

The everyday experiences of people with multiple health conditions draw attention to the problems of ineffective medicines and the demands placed on people to access care, wait for appointments and referrals, and navigate conflicting advice from different care providers. All these problems form part of ‘chronic living’ (Manderson and Smith-Morris 2010; Manderson and Wahlberg 2020). We propose to shift focus from understanding multimorbidity as the accumulation of ‘distinct pathologies’, to what we might learn from its emergence as a historically contingent “matter of concern”. This shift helps to discern certain limits of contemporary care services and can contribute to a better understanding of how we might improve the organisation and delivery of care to lower treatment burdens and avoid overtreatment and futile interventions.

Multimorbidity increasingly forms the lens through which the public health community views the growing burden of population ill-health. As such, it holds a promise of breaking through long-established silos in care (see also Lynch et al. 2022). However, that promise is doomed to fail unless care services address the radical challenge that multimorbidity presents regarding the way bodies have been conceptualised in biomedicine: as containers for diseases. This is also a challenge for social scientists of health, who often tend to reify single disease categories in how they divide the world into ‘patient groups’. The ‘multimorbidity challenge’ should be taken up as an invitation to rethink the body as historically situated, and constantly enfolded in and constituted by its socio-political and ecological environment.

Works cited

 Adan, Muna, Clare Gillies, Freya Tyrer, and Kamlesh Khunti. 2020. ‘The Multimorbidity Epidemic: Challenges for Real-World Research’. Primary Health Care Research & Development 21: e6. https://doi.org/10.1017/S146342361900094X.

Armstrong, David. 2014. ‘Chronic Illness: A Revisionist Account’. Sociology of Health & Illness 36 (1): 15–27. https://doi.org/10.1111/1467-9566.12037.

Barnett, Karen, Stewart W Mercer, Michael Norbury, Graham Watt, Sally Wyke, and Bruce Guthrie. 2012. ‘Epidemiology of Multimorbidity and Implications for Health Care, Research, and Medical Education: A Cross-Sectional Study’. The Lancet 380 (9836): 37–43. https://doi.org/10.1016/S0140-6736(12)60240-2.

Campos, Paul, Abigail Saguy, Paul Ernsberger, Eric Oliver, and Glenn Gaesser. 2006. ‘The  Epidemiology of Overweight and Obesity: Public Health Crisis or Moral Panic?’ International  Journal of Epidemiology 35 (1): 55–60. https://doi.org/10.1093/ije/dyi254.

Ecks, Stefan. 2021. ‘Depression, Deprivation, and Dysbiosis: Polyiatrogenesis in Multiple Chronic Illnesses’. Culture, Medicine, and Psychiatry, February. https://doi.org/10.1007/s11013-020-09699-x.

Fudge, Nina, and Deborah Swinglehurst. 2021. ‘Keeping in Balance on the Multimorbidity Tightrope: A Narrative Analysis of Older Patients’ Experiences of Living with and Managing Multimorbidity’. Social Science & Medicine, November, 114532. https://doi.org/10.1016/j.socscimed.2021.114532.

Hajat, Cother, and Emma Stein. 2018. ‘The Global Burden of Multiple Chronic Conditions: A Narrative Review’. Preventive Medicine Reports 12 (October): 284–93. https://doi.org/10.1016/j.pmedr.2018.10.008.

Ho, Iris Szu-Szu, Amaya Azcoaga-Lorenzo, Ashley Akbari, Corri Black, Jim Davies, Peter Hodgins, Kamlesh Khunti, et al. 2021. ‘Examining Variation in the Measurement of Multimorbidity in Research: A Systematic Review of 566 Studies’. The Lancet Public Health 6 (8): e587–97. https://doi.org/10.1016/S2468-2667(21)00107-9.

Latour, Bruno. 2004. ‘Why Has Critique Run out of Steam? From Matters of Fact to Matters of Concern’ 30 (2): 225–48. https://doi.org/10.1086/421123.

Lynch, Rebecca, Benjamin Hanckel & Judith Green. 2022. ‘The (failed) promise of multimorbidity: chronicity, biomedical categories, and public health’. Critical Public Health, 32:4, 450-461, DOI: 10.1080/09581596.2021.2017854

Martin, Stephen A., Marcy Boucher, James M. Wright, and Vikas Saini. 2014. ‘Mild Hypertension in People at Low Risk’. BMJ 349 (September): g5432. https://doi.org/10.1136/bmj.g5432.

Manderson, Lenore, and Carolyn Smith-Morris. (2010) Chronic Conditions, Fluid States: Chronicity and the Anthropology of Illness. Rutgers University Press. http://www.jstor.org/stable/j.ctt5hj44p.

Manderson, Lenore, and Ayo Wahlberg. (2020) Chronic living in a communicable world. Medical Anthropology, 39 (5), 428-439.

Moynihan, Ray. 2016. ‘Caution! Diagnosis Creep’. Australian Prescriber 39 (2): 30–31. https://doi.org/10.18773/austprescr.2016.021.

O’Brien, Rosaleen, Sally Wyke, Bruce Guthrie, Graham Watt, and Stewart Mercer. 2011. ‘An “Endless Struggle”: A Qualitative Study of General Practitioners’ and Practice Nurses’ Experiences of Managing Multimorbidity in Socio-Economically Deprived Areas of Scotland’. Chronic Illness 7 (1): 45–59. https://doi.org/10.1177/1742395310382461.

Ørtenblad, Lisbeth, Lucette Meillier, and Alexandra R Jønsson. 2018. ‘Multi-Morbidity: A Patient Perspective on Navigating the Health Care System and Everyday Life’. Chronic Illness 14 (4): 271–82. https://doi.org/10.1177/1742395317731607.

Sinnott, Carol, Sheena Mc Hugh, John Browne, and Colin Bradley. 2013. ‘GPs’ Perspectives on the Management of Patients with Multimorbidity: Systematic Review and Synthesis of Qualitative Research’. BMJ Open 3 (September): e003610. https://doi.org/10.1136/bmjopen-2013-003610.

van Blarikom, Esca, Nina Fudge, and Deborah Swinglehurst. 2002. The emergence of multimorbidity as a matter of concern: a critical review. BioSocieties. https://doi.org/10.1057/s41292-022-00285-5

World Health Organization. 2016. Multimorbidity. Technical Series on Safer Primary Care. Geneva: World Health Organization. https://apps.who.int/iris/handle/10665/252275.

Esca van Blarikom is a PhD student at Queen Mary University of London. As a medical anthropologist, Esca is interested in studying health inequities and the intersections of social, psychological, and physical health and health care. https://www.apollosocialscience.org/navigating-complex-systems-of-care/

Deborah Swinglehurst is a General Practitioner and Professor of Primary Care. Her research explores interfaces between medicine, social science and linguistics with a particular focus on the practices of health professionals and patients as they navigate the complexities of contemporary healthcare. 

Nina Fudge is a Lecturer in Social Science and THIS Institute funded Research Fellow with an interest in the use of ethnographic methods for understanding health, and the systems and practices of health care and research. Her research interests include long-term conditions, polypharmacy, and concepts and practices of knowledge production in biomedical research.

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