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By Burden Lundgren
January 20, 2015
In this, my final column, I would like to examine the concept of health more closely. The definition of health suffers from the same problem as the definition of pornography. In the same way that one Supreme Court justice remarked that he couldn’t define pornography but he knew it when he saw it, we also have images of health in our heads. Children running at the beach, leaping ballerinas, even squirming puppies fit our notion of health. It’s a notion we seldom question. Health just looks a certain way.
Except when it doesn’t. Healthy looking bodies can harbor serious health problems. The healthy looking person parking in a handicapped spot may in fact be unable to walk more than a short distance without being out of breath. Even young athletes can be battling serious illnesses. Both the Williams sisters, for instance, have continued their top-rung tennis careers in the face of diagnoses that would bench most of us.
Usually when we think healthy, we also think young. But one of the most famous definitions of health unites health with age. According to Samuel Johnson, “Health is merely the slowest possible rate at which one can die.” The higher the number of years at death, the healthier the individual.
This definition certainly has the satisfaction of a quantitative measure, but it suffers from the same problem noted by Aristotle– call no man happy until he is dead. We cannot then assess the health of an individual until he/she dies. It is discomfiting to assume that a centenarian is healthier than a teenager. Is health really about just the accumulation of years?
Probably the best known definition of health comes from the World Health Organization (WHO). “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” So two conditions have to be met.
Let’s take the last part first. “The absence of disease or infirmity” implies that health is a binary concept. Either you have an infirmity or you don’t. But how is this determined? If I am coughing and achy, I can affirm that I am sick, but the real arbiters of illness among us are usually physicians (at least in Westernized countries). They are the ones who give us diagnoses, the formal name of a disease or infirmity. Once named, we join those who are no longer healthy – which, as it turns out, is almost everyone.
Between the epidemic of chronic disease and high-tech diagnostic techniques, “disease” is where most of us find ourselves. No matter how much we devote ourselves to “wellness,” health by this definition, in fact, is not the human default status. It is a temporary state when it exists at all.
But what constitutes “disease” is somewhat evanescent. Chlorosis was a common diagnosis for young women in the 19th century. Neurasthenia, another common 19th century diagnosis, is still recognized by WHO and in China, but not in America. Premenstrual syndrome and restless leg syndrome were either discovered or invented in the 20th century. There are conditions that moved from a sin to a disease (e.g., alcoholism) and the sin that moved to a disease to a normal variant (homosexuality). Then there is the concept of pre-disease, e.g., pre-hypertension, pre-diabetes. How do these fit into a binary paradigm? And where do risk factors fit in?
If the health/disease part of the WHO definition leaves us in the weeds, the well-being part takes us into a thicket. First, there is the “physical, mental and social” difficulty. We may be comfortable assigning responsibility for addressing physical and mental well-being to physicians, but the word “social” seems to take us beyond medical purview.
But whose purview is it? And to what lengths does it extend? Are we talking here about simple concepts such as living alone? Or are we talking about what is known as “social medicine”?
Social medicine comes to us from the 19th century and ties social and economic conditions to illness and health. The ties are valid. Population health is far more correlated to factors such as income and education than it is to health care per se. If we look to physicians who influence these factors, we are looking to public health specialists rather than to individual practitioners. And beyond them, we are looking to policymakers, those who plan and govern our communities.
Once past “physical, mental and social,” we come to “well-being.” The definition of well-being nearly always includes the word “health.” So we still do not know what health is, but the idea of well-being does bring in another perspective. Well-being is something that can be assessed only by the individual and can exist even in the face of serious diagnoses. Physicians may determine health, but only we know-how we feel.
So despite the circularity of the definitions of health and well-being, if we cede the determination of health to physicians and the determination of well-being to individuals, we set up areas of both agreement and dissonance. We may go into our doctor’s office feeling fine only to be told we have a serious disease. We may also have the experience of telling a doctor we don’t feel well only to be told that our tests are normal so our problems are “all in our head.”
Over populations, well-being is associated with decreased risk of disease, illness and injury; better immune functioning; speedier recovery and greater longevity – which brings us back to Samuel Johnson and even, perhaps, to Aristotle. If our lives are long and happy, we have been healthy no matter what diagnoses come attached.
Author: Burden S Lundgren, MPH, Ph.D., RN practiced as a registered nurse specializing in acute and critical care. After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk, Virginia. She has served as a consultant to a number of nonprofit groups. Presently, she divides her time between Virginia and Pennsylvania and is working on two books – when her cocker spaniels let her. She can be reached at [email protected].