Redefining ‘health’ for the 21st Century

The history of healthcare has not ended.

Categorising illnesses and identifying their links to a range of pathogens, vectors, and genetic predispositions, has provided humanity with a clear road map for addressing health needs within our species as a whole. This path has served us spectacularly well, lifting countless millions out of suffering and into near-guaranteed long and healthy lives. While we still have some of the path left to walk (e.g. neglected tropical diseases, see @teemike‘s recent great post for more on this topic), our well-worn road map for health is becoming less and less viable when it comes to the world of modern healthcare. ^{Title image adapted from: pixabay}

The World Health Organisations place in history

When the World Health Organisation (WHO) settled on a definition for the concept of ‘health’ in 1946, it was groundbreaking in its scope and ambition. 70 years later they still have the definition front and centre of their global mission, defining health as:

“… a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” ¹

At its conception, the definition formally marked a sea change in the history of healthcare.

Up until the beginning of the 20th century, the biomedical model of healthcare ruled supreme. Influenced by the early scientific findings of Darwin and the other great natural scientists of the 19th century, the biomedical model saw human beings as biological entities, similar in nature to the other animals being studied using the scientific method at the time. As such, 19th century healthcare treated people with a similar level of scientific objective detachment ².

Illness, during this time, was seen as an invasion from outside the body or due to internal involuntary physical changes. Treatment of illness therefore aimed to change the physical state of the body and return it to ‘normal’ functioning. The biomedical model also adhered to the Cartesian notion of dualism, whereby the mind and the body are thought of as distinct and separable entities. Illness could have psychological consequences, as the mind comprehended the physical suffering, but not be the cause of, or be exacerbated by, internal thought processes.

The 1948 definition of health from the WHO therefore surpassed the biomedical model of healthcare and went as far as to indorses the biopsychosocial model of medicine with its focus on “physical, mental and social wellbeing”.

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This aspect put the definition far ahead of its time. Not only was this compressive view of health from the WHO suggested a full 30 years before the term biopsychosocial was official coined by George Engel in 1977 ³, but also it’s an ideal that many, if not all, health systems are still aspiring to.

There is, however, a single word within their definition that has caused many within healthcare to push for change.

That word is:

“complete”

The quest for complete health makes us all unhealthy

If we assume that the WHO’s definition of health guides the organisations actions, then this single word may prove to change our world in incalculable ways.

While it is admirable to aim high, “complete well-being” is a tricky concept to design policy around. In its current conception, many doctors see health as a negative state, defined by the absence of disease rather the presence of health. As such, as our ability to conduct blood tests, genetic analysis and advance imaging techniques increases in sophistication we will soon discover that we are, all of us, to some degree “unhealthy” ⁴.

Take for example the emerging medical concept of pre-diabetes. People with pre-diabetes have no symptoms of diabetes related to ill health, however, their blood sugar levels are at the high end of the normal range. With pre-diabetes being officially recognised by the American Diabetes Association in 2010, a third of adults in England and half of adults in China now fit this diagnosis ⁵

In an ideal world, the most positive outcome of this diagnosis would be to spur behaviour change in the form of adhering to a healthy balanced diet and being physically active. However, of course, we live in far from an ideal world. With so many potentially “unhealthy” individuals, pharmaceutical companies may see this as a tremendous growth opportunity for their businesses and move to encourage the use of the term as justification.

My argument here isn’t to say that medications are not a necessary part of a healthcare system (in fact I have a sizable chunk of my soul devoted to loathing people with little understanding of health suggesting that their alternative, made-up, fantasy version of healthcare is somehow superior) but to instead argue for the scope of healthcare to push out further than mere diagnosis and treatment.

Demographic shift

An aging population makes the issue of over medicalisation in high and middle-income countries a pressing issue. In the next couple of years people aged greater than 65 globally will outnumber those less than 5 years of age for the first time in history. This proportion will only continue to grow over the next century⁶. With the majority of those over 65 years old living with at least one chronic disease, the WHO definition again becomes counterproductive.

It may very well be the case that a 25 year old may feel unhealthy when they are out of breath after reaching the top of three flights of steps, whereas a 70 year old may climb the same flight of steps and be out of breath, but feel that they are healthy for doing so. In this regards the perspective of health becomes the aspect that reflects well-being, rather than the objective physical response.

Don’t get me wrong I’m still all in favour of slaying the dragon tyrant of death but just with more of a focused on doing so in a way where we’re not causing more problems than we solve.

Widening the scope of health

So, it would seem that we’re missing a few aspects from a definition that will allow us to gain the best health outcomes across this new, far more complicated, century of healthcare. For instance, health gains in survival years may be less relevant that an aspect such as societal participation, and an increase in coping capacity may be more relevant, and realistic, than complete recovery.

As such, some within health care are arguing for “the ability to adapt and to self-manage” ⁷ to be included on par with the treatment of illness. For bio-health this may involve an increased focus on developing a health body that can better withstand physical harm and diseases. For the psycho-health, this may involve the development of coping strategies for anxiety and depression issues before they set in. For social-health, this may involve insuring that the elderly are able to have an active and engaging social life ⁷.

With this pivot, the role of “the doctor” changes dramatically to more of an empathiser and life style adviser rather than diagnoser and medicator. The alternative health community do this particularly well, consultations can often last the best part of an hour and be deeply caring (however they also often ruin it by including unnecessary, sometimes dangerous, often expensive interventions that have either misunderstood or completely ignored the idea of evidence and basic reason). Therefore, if I were to change one thing in the healthcare system (not that you asked) it would be to give each patient an extra 5 minutes with a healthcare professional, each consoltation, to plan for the future. Don’t worry fellow healthcare professionals I do realise just how ruinously expensive this change would be. It’s a shame, so many problems could be solved with such a simple change.

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About me

My name is Richard, I blog under the name of @nonzerosum. I’m a PhD student at the London School of Hygiene and Tropical Medicine. I write mostly on Global Health, Effective Altruism and The Psychology of Vaccine Hesitancy. If you’d like to read more on these topics in the future follow me here on steemit or on twitter @RichClarkePsy.

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References:

[1] The World Health Organisation: faq: What is the WHO definition of health?
[2] Ogden, J. (2012). Health Psychology: A Textbook McGraw-Hill Education (UK).
[3] Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129-136.
[4] Smith, R. (2008). The end of disease and the beginning of health. BMJ Group blogs.
[5] The BBC: Pre-diabetes label 'worthless', researchers claim
[6] He, W., Goodkind, D., & Kowal, P. R. (2016). An aging world: 2015(pp. P95-16). Washington, DC: United States Census Bureau.
[7] Huber, M., Knottnerus, J. A., Green, L., van der Horst, H., Jadad, A. R., Kromhout, D., ... & Schnabel, P. (2011). How should we define health?. Bmj, 343, d4163.