How should health be defined?BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a2900 (Published 10 December 2008) Cite this as: BMJ 2008;337:a2900
- Alejandro R Jadad, professor ,
- Laura O’Grady, postdoctoral fellow
- 1Centre for Global eHealth Innovation; Department of Health Policy, Management and Evaluation; Dalla Lana School of Public Health; Faculty of Medicine, University of Toronto; and University Health Network, Toronto, Canada M5G 2C4
On 7 April 1948, the member states of the United Nations ratified the creation of the World Health Organization. It was set up with the fundamental objective of “the attainment by all peoples of the highest possible level of health.” This lofty goal was coupled with an equally ambitious opening statement that defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”1
This definition invited nations to expand the conceptual framework of their health systems beyond the traditional boundaries set by the physical condition of individuals and their diseases, and it forced us to pay attention to what we now call social determinants of health. Consequently, WHO challenged political, academic, community, and professional organisations devoted to improving or preserving health to make the scope of their work explicit, including their rationale for allocating resources. This opened the door for public accountability.
But the founding principles of WHO are still unfulfilled because many countries have failed to reduce the staggering numbers of premature deaths or to cope with the onslaught of chronic complex conditions. The Millennium Development Goals, most of which are directly or indirectly related to health, may not be achieved by 2015, as was initially envisioned,2 and are unlikely to be met in the next two decades.3 In addition, the ageing population is increasing the prevalence of chronic incurable diseases, which are associated with 60% of deaths worldwide and more than 80% in low to middle income countries.4
So what does the future hold? Were the goals set in 1948 too ambitious? Is the concept of health a “deception”?5 Should we lower or readjust our expectations about our ability to decrease the number of premature deaths and our power to conquer chronic diseases? Is it even possible to reach a basic level of agreement on the meaning of the word health? Is health a construct that can be defined and measured? Can any definition of health be operational?
The biomedical literature is of little help. A search of Medline from 1950 to June 2008—with the terms “World Health Organization”, “health”, and “definition” (or “defined”)—yielded 2081 citations. Of these, only a handful focused specifically on the definition of health.6 7 8 9 10 Some of these articles highlight its lack of operational value and the problem created by use of the word “complete.” Others declare the definition, which has not been modified since 1948, “simply a bad one.”10 11 More recently, Smith suggested that it is “a ludicrous definition that would leave most of us unhealthy most of the time.”5 Interestingly, a Google search on 23 July 2008 using the terms “health” and “definition”, yielded more than 14 million hits, with Wikipedia, not WHO as the top hit.
Witnessing the rapid rise of wikis, blogs, and many other online social networks (such as FaceBook, YouTube, and MySpace), we wonder if we are ready for what has been called the Fifth Estate,12 a new form of civil society participation, enabled by the growing use of the internet, mobile phones, and related information and communication technologies. This is why we have created a blog on http://blogs.bmj.com/bmj/2008/12/10/alex-jadad-on-defining-health/ that includes the original definition of health as proposed by WHO in 1948, and an invitation to anyone with internet access to comment on it, to challenge it, or to try to enhance it.
In the end, we might conclude that any attempt to define health is futile; that health, like beauty, is in the eye of the beholder; and that a definition cannot capture its complexity. We might need to accept that all we can do is to frame the concept of health through the services that society can afford, and modulate our hopes and expectations with the limited resources available, and common sense.
Cite this as: BMJ 2008;337:a2900
Competing interests: None declared.
Provenance and peer review: Commissioned based on an idea from the authors; not externally peer reviewed.