Re-defining ‘Health’

Article: Üstün & Jakob. 2005;83:802

Üstün and Jakob’s timely editorial (1) stresses the need for detailing meaningful definitions for health conditions. Most of the definitional issues raised by the authors with regards to ‘Drowning’ apply to the definition of ‘Health’. Although concern with health and disease have been a major pre-occupation of humans since antiquity, the use of the word ‘health’ to describe human ‘well being’ is relatively recent. The word ‘health’ was derived from the old English word ‘hoelth’, which meant a state of being sound, and was generally used to infer a soundness of the body (2). Prior to the period of the somewhat enigmatic physician known as Hippocrates (c 460-377 BCE, or more appropriately, from around 5 BCE), health was perceived as a divine gift. Hippocrates was credited with the pioneering the move away from divine notions of health, and using observation as a basis for acquiring health knowledge. He was credited with encouraging a focus on environmental sanitation, personal hygiene and, in particular, balanced diets – “let food be thy medicine; and let thy medicine be food”. He theorized that what we currently regard as ‘health’ might be defined as the extent of a delicate balance of four fluids: blood, yellow bile, black bile, and phlegm. Ill health, he believed, resulted from an imbalance of these fluids.

Nevertheless, a divine view of health persists to this era. For example, Prophet Mohammed view of health, sickness and death – followed by a high proportion of practicing Muslims - may be inferred from the following verse in the Holy Koran; “The Lord of the worlds; it is He who heals me when I am sick, and He who would cause me to die and live again” (Koran 26: 80). Health Belief Systems also influence perspectives on the meaning of health. For instance, Becker’s Health Belief Model (3) might be used to explain differences in how the concept of health is perceived by individuals and groups - particularly in non-religious contexts - and how such perceptual differences influence response to ill health (4). But what is ‘Health’ in the 21st century?

Scores of definitions of ‘health’ are available on the Internet. The most commonly quoted definition of health is that formalized by the World Health Organization (WHO) over half a century ago; “a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity.” (5). Several other generally accepted definitions of the noun ‘health’ exist. Bircher (6) defines health as “a dynamic state of well-being characterized by a physical and mental potential, which satisfies the demands of life commensurate with age, culture, and personal responsibility”, while Saracchi defines health as “a condition of well being, free of disease or infirmity, and a basic and universal human right” (7). Australian Aboriginal people generally define health thus “…Health does not just mean the physical well-being of the individual but refers to the social, emotional, spiritual and cultural well-being of the whole community. This is a whole of life view and includes the cyclical concept of life-death-life (8).

Critics argue that the WHO definition of health is utopian, inflexible, and unrealistic, and that including the word “complete” in the definition makes it highly unlikely that anyone would be healthy for a reasonable period of time. It also appears that ‘a state of complete physical mental and social well-being’ corresponds more to happiness than to health (7). The words ‘health’ and ‘happiness’ designate distinct life experiences, whose relationship is neither fixed nor constant. Failure to distinguish happiness from health implies that any disturbance in happiness, however minimal, may come to be perceived as a health problem.

Bircher’s definition takes into account changing health needs, especially in relation to age, culture, and personal responsibility. Health Belief Systems, which are a essentially function of age, culture, and personal responsibility, strongly influence subjective experience of health and ill-health (6). Sarrachi’s definition provides an intermediate concept, linking the WHO’s ideal to contemporary issues of human rights, equity, and justice. Aboriginal Australians incorporate community health and spiritual well being as core aspects of the definition of health. These and other definitions introduce valuable concepts that may be used to enrich and revise the current WHO definition of health. A useful starting point for such revision and enrichment might be for the WHO to clarify its philosophy for ‘Health’ in the 21st century (9).

Niyi Awofeso.

References:

• Üstün B., Jakob R. Calling a spade a spade: meaningful definitions of health conditions. Bull World Health Organ 2005;83:802.
• Dolfman M. The concept of health: an historic and analytic examination. Journal of School Health 1973;43:491-7.
• Becker M. The health belief model and personal health behaviour. Thorofare, NJ: Slack, 1974.
• Golub JE, Bur S, Cromin WA et al. Patient and health care system delays in pulmonary tuberculosis diagnosis in a low incidence state. Int. J. Tuberc. Lung Dis. 2005;9:992-8.
• WHO. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June 1946, and entered into force on 7 April 1948.
• Bircher J. Towards a dynamic definition of health and disease. Med. Health Care Philos 2005;8:335-41.
• Saracci R. The World Health Organization needs to reconsider its definition of Health. BMJ 1997;314:1409-10.
• National Health and Medical Research Council. Promoting the health of Indigenous Australians. A review of infrastructure support for Aboriginal and Torres Strait Islander health advancement. Final report and recommendations. Canberra: NHMRC, 1996: part 2: 4.
• Nijhuis H. G., Van der Maesen L. J. G. The philosophical foundations of public health: an invitation to debate. J. Epidemiol. Community Health 1994;48:1-3.

Niyi Awofeso: Associate Professor, School of Public Health and Community Medicine, University of New South Wales, Sydney 2052, Australia (email: niyi.awofeso@justicehealth.nsw.gov.au).