Redefining ‘health’ for the 21st CenturysteemCreated with Sketch.

in steemstem •  last month

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.


The Agnew Clinic
by Thomas Eakins public domain

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”.


Image created for post

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.


Image credit: pexels

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.


Image credit: Free stock photos

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.

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Hello there again @nonzerosum :)

I love the overview you provided here on the transition of the biomedical model to the biopsychosocial model, which is of paramount importance in the field of psychology. I suppose this is one of the gripes psychologists have towards most psychiatrists, who seem to still be over attached to the former approach!

I am also incredibly interested in a self-manage 'program' addressing both physical and mental health. Something that can only begin to take place by means of education, information and a shift in the mindset of the patient, the health professional and first and foremost the system that accommodate them.

Thank you for this great article.
Wishing you all the best :)

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Hi Abigail,
That’s so kind of you to say, thank you!

Even within psychology, this approach seems to be largely neglected when it comes to health. I’m teaching health psychology this coming semester. The students have to pick between taking health psychology or taking forensic psychology. Forensic always wins out!

Yes, the major challenge for health this century is probably going to be - How can we create a society that keeps itself healthy?

Thank you again for your support! :-)

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

I smiled when I remember I had to memorise this definition of health for an exam.
I always fall in love with the way you combine philosophy with health.
The concept of who is healthy and who isn't may soon not reach a consensus but with time I believe we could get there. Take for instance, in some parts of Nigeria, being overweight/obese used to be considered as being healthier than being slim. Knowledge of diseases associated with being overweight has made some accept the fact that they are actually not healthy. With time knowledge will permeate into many misconceptions. "Some" is emphasised because there is social and psychological advantage attached to being overweight. I guess we still have a long way to go.

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.

lol....I"m still of the school of thought that life in its entirety is a sort of balance. Every phase we pass through, healthy or unhealthy, life and death are in a kind of balance. Maybe no one was meant to be completely healthy because I doubt is achievable. So I'd agree with you.

I love your article bro. Kudos!

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Hey, thanks mate, really appreciate your kind words!

… in some parts of Nigeria, being overweight/obese used to be considered as being healthier than being slim. Knowledge of diseases associated with being overweight has made some accept the fact that they are actually not healthy. With time knowledge will permeate into many misconceptions. "Some" is emphasised because there is social and psychological advantage attached to being overweight.

This is an excellent point that demonstrates the nuance in health so so well! Love it!
It’s exactly the reason why quantifying ‘health’ accurately is so hard, the trade-offs are really complicated.

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Thank you. You always inspire me.

I love this, but then we do tend to love things that fall in with our world view. I'm a bit older than many people on Steemit, and so perhaps may be a bit more philosophical about what it means to be 'healthy'. My posture embodies a kind of zen acceptance of what is mixed with modest use of Western tools. Heaven knows, something will always be found at the bottom of a test tube that might warrant 'looking into'. This is particularly true in the U.S. if one has good insurance :)
This is a lovely, gentle blog--a pleasure to read.

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Hi @agmoore, thank you so much for your comment.

Heaven knows, something will always be found at the bottom of a test tube that might warrant 'looking into'

This is a great way of putting it. The trick here is to untie the health gains from the profit motive (a spectacularly hard thing to do!). Right now (with the NHS in the UK) healthcare professionals are the best way to do this, however there workload is high and often only allows for around a 10-15 minutes consultation. Private might be different. I have some friends that do research into the incentive present in the different systems, I’ll no doubt look into it at some point.

…gentle blog

Ha, yes, exactly what I’m aiming for!

Thank you for your kind words, I have your microgrid post open on one of my ‘to read’ tabs at the moment, also one of my interests (if a grid goes down it’s a massive public health issue!)

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I think an ideal model for healthcare delivery can be found in Cleveland Clinic. It resembles the NHS in some ways but doesn't seem to have the severe budgetary constraints. All the physicians work on salary, so there is no incentive to do "more". And yet, the Clinic always rates at or near the top in US healthcare centers. Recently Cleveland published a paper about changing the healthcare model for the 21st century. You may be familiar with the Cleveland model and have a critique. I just briefly glanced at this 'new direction' paper and like the way the hospital is responding to patients' wishes.
I'm a great supporter of NHS, but think (from what I've read) the system is being strangled by budget constraints. We have the same tug and pull in this country.
As for being gentle-- I look for that in doctors, and bloggers :)

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I'm not aware of the Cleveland model, but from what you say I'd agree that this has all the basic ingredients for a good health system. I'll take a look, thanks!

Yeah, its the same story as in the post, ageing population puts a lot of pressure on the system. We're very short of nurses at the moment, its a worry.

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I think I'm part of that aging population--but I do my best not to overuse the system. Sometimes the consumer has to decide when to say "no". Thanks for your thoughtful reply.

Interesting to know that the social part was already on the table 70 years ago. I mistakingly thought this to be a much more modern concept.

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I know, right! Good on them for being ahead of mainstream on this one.

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I know, right! Good on
Them for being ahead of
Mainstream on this one.

                 - nonzerosum


I'm a bot. I detect haiku.

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Ha! This is the kind of shit that I love about this platform. Nice try bot, I appricate the effort.

congratulation nonzero-sum happy to see you on health tag trending...

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Hi @babai1995, thank you! Have you ever thought about writing for the #steemSTEM tag? From a look at some of your previous posts, some of your content would fit nicely. Here’s a style guide if you’re interested.

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what can I do for you, I view your suggested posts.



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