The meanings of health and its promotion.

The Constitution of the World Health Organization, which came into force on April 7, 1948, defined health “as a state of complete physical, mental and social well-being.” The writers of the Constitution were clearly aware of the tendency of seeing health as a state dependent on the presence or absence of diseases: so they added to that definition that an individual, if he is to be considered healthy, should not suffer from any disease (….“and not merely the absence of disease or infirmity”) (1). In that way, the definition of the World Health Organization simply added a requirement to the previous position that allowed to declare someone healthy if no disease could be found: the step forward that could have been taken in the conceptualization of health as a dimension of existence which can co-exist with the presence of a disease or impairment was thus not taken. Today, three types of definition of health seem to be possible and are used. The first is that health is the absence of any disease or impairment. The second is that health is a state that allows the individual to adequately cope with all demands of daily life (implying also the absence of disease and impairment). The third definition states that health is a state of balance, an equilibrium that an individual has established within himself and between himself and his social and physical environment. The consequences of adopting one or another of these definitions are considerable. If health is defined as the absence of disease, the medical profession is the one that can declare an individual healthy. With the progress of medicine, individuals who are declared healthy today may be found to be diseased tomorrow because more advanced methods of investigations might find signs of a disease that was not diagnosable earlier. How an individual feels about his or her state is not relevant in this paradigm of health. How the surrounding people judge the behavior and appearance of an individual is only relevant if their observations are congruent with the criteria of abnormality that the medical profession has produced. The measurement of the state of health of a population is also simple and will involve no more than counting the individuals who, on examination, show defined signs of illness and comparing their numbers with those who do not. There are obvious difficulties with the first and the second of the definitions mentioned above and with their consequences. There are individuals who have abnormalities that can be counted as symptoms of a disease but do not feel ill. There are others whose body tissues do not demonstrate changes but who feel ill and do not function well. There are people who hear voices and might therefore be candidates for psychiatric examination and possibly treatment – but live well in their community and do not ask for nor receive medical care. There is a significant number of people who have peptic ulcers and other diseases, experience no problems, do not know that they have a disease and do not seek treatment for it. Some of these individuals will also escape the second type of definition of health because they function as well as expected in their age and gender group of the general population. The third definition mentioned above makes health depend on whether a person has established a state of balance within oneself and with the environment. This means that those with a disease or impairment will be considered as being healthy to a level defined by their ability to establish an internal equilibrium that makes them get the most they can from their life despite the presence of the disease. Health would thus be a dimension of human existence that remains in existence regardless of the presence of diseases, somewhat like the sky that remains in place even when covered with clouds. The advantage of this definition is that diseases do not replace individuals’ health: they may affect their balance more or less severely but, at all times, the patients who suffer from a disease (and their doctors) remain aware of the need to work simultaneously on two tasks – one, to remove or alleviate the disease and the second to establish a state of balance, as best they can, within oneself and in relation with their environment. In fighting stigmatization that accompanies many chronic and some acute diseases – such as mental disorders or leprosy – this definition is also useful because it makes us speak and think about our patients as people who are defined by different dimensions (including health) and who, at a point, suffer from a disease – and thus make us say “a person with schizophrenia” rather than “a schizophrenic,” or a ”person who has diabetes” rather than a “diabetic” and a “person with leprosy” rather than a “leper.” There is another important consequence of working with this definition of health. To establish whether someone is in good health in accordance with this definition, the doctor must explore how individuals who have a disease feel about it, how the disease influences their lives, how they propose to fight their disease or live with it. Laboratory findings and the presence of symptoms are thus important and necessary ingredients in thinking about the state of health and the presence of a disease but are not sufficient to reach a decision about someone’s health: it is necessary to view the disease in the context of the person who has it in order to make a judgment about his or her level of health. There is little doubt about the fact that going about the treatment of diseases in this way would improve the practice of medicine and make it a more realistic as well as a more humane endeavor. The promotion of health is also affected by the differences in the definition of health. The simplest definition of health – equated with the absence of disease – would lead to a definition of the promotion of health as an effort to remove diseases and diminish the numbers of individuals who suffer from them. The involvement of functioning in the definition of health would be reflected in defining the promotion of health as a process by which the capacity of individuals to cope will be enhanced and strengthened, for example by regular and obligatory physical exercise. Both of these definitions would lead to recommendations to improve the treatment of diseases, and to remove risks factors that might lead to them – such as sedentary life style, smoking, bad eating habits and insufficient application of hygienic measures such as washing one’s hands before meals. The third definition of health, by its very nature, could not stop at efforts to remove diseases and to diminish risk factors that might lead to disease. It would have to involve the individuals whose health is to be promoted in an active way: it would have to address the scales of values of individuals and communities to ensure that health is placed higher on those scales. High value placed on health (not only on the absence of disease) would make people undertake whatever is necessary to enhance health: participating in preventive action and seeking treatment would become a normal expression of the need to behave in harmony with one’s own and one’s community values. Changing the place of health on the scale of values, however, is not possible if left to the health sector alone: values are shaped throughout life under the influence of parents, friends, schools, the media, laws, and one’s own life course and experience. Thus, changing values – for example to give health a higher value, to promote health – has to be a task for all of those involved in shaping values and placing them on a scale rather than for the health system alone. The huge challenges that face societies aiming to improve the health of their citizens will not be appropriately answered if we do not change the paradigms of health and disease and design strategies for future work using these new paradigms. Their formulation and acceptance is a task that is before all of us and is urgent.