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Recent rapid responses
Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.
Displaying 1-10 out of 21 published
16 December 2012
Huber and colleagues bring needed attention to the WHO definition of health. Their suggestions are to move the definition toward adaptation and self-management in the face of challenges. (1) However, since challenges to be faced in life can never be known until they occur, their suggestion would encourage reactive instead of proactive actions by individuals and professionals. This author suggests it is necessary to define health, as WHO has done, in a way that inspires the desire to improve physical, mental and social well-being for its own sake. By doing this, abilities to adapt and self-manage are improved as a better life is created. (2-5)
Improved health provides an opportunity to manifest a better life. Health is a dynamic, not static state that one must work to continuously generate. Health is not something that can be achieved by reacting to current circumstances. The WHO definition provides an ideal state to work toward by defining health as a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity (6).
Humans have a unique, innate ability and desire to adapt and continually improve their state of well-being. Health is not as much an end point as it is an enabling capacity to facilitate progress toward a desired life. Huber and colleagues’ commentary suggests that the WHO definition would consider most individuals to be unhealthy or definitively ill most of the time and that this would then lead to the undesired outcome of increased medicalization. (1) This interpretation is correct if health is understood to be the absence of disease and infirmity and not as the presence of well-being.
WHO explains that health is the PRESENCE of physical, mental and social well-being and not merely the ABSENCE of disease and infirmity. (6) Only conscious action can create these desired states of well-being. Seeing health as the absence of disease and infirmity is narrow and incomplete. Instead of defining health as a higher state to be created and continually achieved, Huber and colleagues suggested redefinition would seem to encourage a return to a predetermined baseline instead of a move toward a higher state of well-being. Putting a focus on the precursors to achievement, accomplishment and thriving, something required with the current definition, inspires action to enhance physical, mental, and social well-being.
Though we are pulled to the status quo or maintenance by the endowment effect, (7) it does not inspire. Furthermore, passive reactionary stances and maintenance of the status quo through "…the ability to adapt and to self-manage" would be encouraged if this redefinition were accepted. Accomplishment and achievement of one’s desires, on the other hand, inspires action. The current WHO definition inspires action to create a dynamic and improving state of health that can be measured by determining engagement in health promoting actions. Results document that the more people engage in health promoting actions, the greater their well-being, satisfaction, and performance and the lower their incidence of symptoms and problems associated with disease and infirmity because of a better ability to adapt and self-manage in the face of challenges. (8,9)
(1) Huber M, Knottnerus JA, Green L, Horst H, Jadad AR, Kromhout D, et al. How should we define health? BMJ 2011;343.
(2) Breslow L. A quantitative approach to the World Health Organization definition of health: physical, mental and social well-being. Int J Epidemiol 1972 Winter;1(4):347-355.
(3) Breslow L. From disease prevention to health promotion. JAMA 1999 Mar 17;281(11):1030-1033.
(4) Antonovsky A. Unraveling the mystery of health : how people manage stress and stay well. 1st ed. San Francisco: Jossey-Bass; 1987.
(5) Becker C, Glascoff M, Felts W. Salutogenesis 30 Years Later: Where do we go from here? International Electronic Journal of Health Education 2010;13:25-32.
(6) World Health Organization. World Health Organization Constitution. Dublin: Stationery Off; 1948
(7) Ariely D. The upside of irrationality : the unexpected benefits of defying logic at work and at home. New York, NY: Harper; 2010.
(8) Becker CM, Whetstone L, Glascoff M, Moore J. Evaluation of the Reliability and Validity of an Adult Version of the Salutogenic Wellness Promotion Scale (SWPS). Am J Health Educ 2008;39(6):322-328.
(9) Becker CM, Dolbier CL, Durham T, Glascoff MA, Adams TB. Development and Preliminary Evaluation of the Validity and Reliability of a Positive Health Scale. Am J Health Educ 2008;39(1):34-41.
Competing interests: None declared
East Carolina University, 3207 Carol Belk Building; Greenville, NC, 27858; USA
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6 February 2012
The definition of health as the "ability to adapt and to self manage" is an important step toward a full comprehension of health and disease. In fact, the question about the nature of health is overwhelming. To answer it, we have to ask: When do we not feel healthy? We can easily answer: When we cannot do something that we used to or something that people commonly do. For instance, when we can no longer run as swiftly as we used to, or when a disease inhibits eating food that people commonly eat. To drink, to walk, to eat ice cream, to read a good book; to restore breathing if our nose is obstructed, to restore sight if we are blind or to kill pain if we have a headache - to be healthy is to realize this. The awareness that our desires are being realized is what we call well-being: in other words, the awareness of health. It is important to affirm that, even in the case of chronic diseases, health is possible, first because many disabled people show how to be healthy despite their disability (e.g. Paralympic champions or world famous blind singers such as Andrea Bocelli or Ray Charles); second, because precluding disabled people from health to is relegating them to a second-class personhood.
The only flaw I see in this paper's definition of health is that it highlights only the active aspect of an healthy person, while even when dependent on others a human being maintains his/her dignity and therefore his/her possibility of health: the opposite of health is not the lack of autonomy, but the lack of hope.
References:
Bellieni CV, Buonocore G: Pleasing Desires or Pleasing Wishes? A New Approach to Health Definition. Ethics and Medicine 2009;25(1):7
Carlo V. Bellieni
Pontifical Academy for Life
University Hospital, Siena (Italy)
Competing interests: None declared
University Hospital, Siena, via delle province, 8
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+18 September 2011
The proposed new definition for health risks further blurring of the health - disease transitions and possibly would lead to an oxymoronic state of 'healthy disease'. Would a single mum in a poor country working during her bout of flu be termed healthy since she is able to adapt and self manage whereas a young adult in a rich country who is 'off sick from work' with flu might be termed as unhealthy.(1).
The general public would define health as absence of disease. The problem lies with definition of diseases not with definition of health. Ever expanding pre-disease categories and risk factors are increasingly viewed as physical disease. (2). 'Normal life events' are increasingly categorised as mental health problems. (3).
The availability of rapid genome wide sequencing might detect low penetrant disease risk genes in practically most of us and this potentially can put most of us in some pre-disease categories.(4).
Hence there is an urgent need to define disease before we define health. Otherwise concept of 'health' risks becoming a philosophical concept discussed along with 'meaning of life'!
References: 1. Huber M, Knottnerus JA, Green L, van der Horst H, Jadad AR, Kromhout D et al. How should we define health? BMJ. 2011 Jul 26;343:d4163. doi: 10.1136/bmj.d4163.
2. Moynihan R. Medicalization. A new deal on disease definition. BMJ. 2011 May 3;342:d2548. doi: 10.1136/bmj.d2548.
3. Frances A. The first draft of DSM-V. BMJ. 2010 Mar 2;340:c1168. doi: 10.1136/bmj.c1168
4. Cirulli ET, Goldstein DB. Uncovering the roles of rare variants in common disease through whole-genome sequencing. Nat Rev Genet. 2010.Jun; 11(6): 415-25.
Competing interests: None declared
Nottingham University Hospitals NHS trust
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+16 September 2011
Dear Editor,
Re: Huber et. Al. How should we define health?
As a participant at the international conference referred to in the above paper (my contributions to these debates is acknowledged by the authors) I would like to make three comments on the ideas they present.
1. The authors fail to appreciate what for many is the key strength of the WHO definition which paradoxically is a weakness of the approach they are proposing. The WHO definition is 'aspirational' aiming to guide national and global health governance not to provide a conceptual framework for operationalising 'health' in a narrow technical sense.
2. The WHO definition was the product of an inclusive dialogue involving 'lay' and professional/medical experts. If there is to be a change in the way that international health governance agencies define health then it surely is not acceptable in the 21st century for this to be done without wide-ranging engagement beyond the esoteric world of academia and the pragmatic world of policy. Civil society should have a voice.
3. The authors' new definition of 'health' places undue emphasis on
individuals and their "ability to adapt and to self manage" irrespective
of their context. If one accepts that it is worthwhile to pursue a new
definition amenable to operationalisation - and I am not convinced of this
- then this process needs to attend to the implications of the burgeoning
literatures on:
a. the complex concepts of capability, capacity and resilience where
research points to the importance of conceptualising these as
characteristics of the relationship between individuals and the socio-political systems in which they are embedded (or even as characteristics
of these systems themselves) rather than as located with individuals.
b. The role of collective social dynamics and/or relationships in the
genesis, promotion, management and sustainability of health, wellbeing and
functioning
c. Lay/patient generated measures of health and health outcomes (e.g
patient reported outcome measures) which allow individuals to identify the
domains of health, wellbeing and social functioning that are important to
them.
The authors argue that the "formulation of health as the ability to adapt and to self manage... could be a starting point for a fresh, 21st century way of conceptualising human health and that discussion with other stakeholders should continue. Indeed it should. I fear that the approach proposed by Huber et. al. results in a narrowly individualistic psycho-social definition of health. The social determinants approach, emphasising political, economic, social and cultural pathways to health and health inequalities provides a more appropriate 21st century framework to underpin national and global health governance.
Competing interests: I participated in discussions at the workshop that the authors Huber et. al. draw on for their article.
Lancaster University UK
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+9 September 2011
We certainly agree with the recommendation by Machteld Huber et al, resulting from a recent meeting of experts at a Dutch conference, that WHO update their definition of health and place 'emphasis towards the ability to adapt and self manage in the face of social, physical, and emotional challenges.'1. We appreciate the concept of 'dynamic balance between opportunities and limitations' in the social domain.
However we are concerned that the proposed definition's emphasis on personal and community responsibility for adaptation and self-management denies the reality that some social determinants may preclude the ability of individuals and communities to adapt to their circumstances.
We believe that the authors and WHO would benefit from applying a much wider lens to the etiology of health, and therefore increase the recommendations to support maximum health around the world. The physical, mental, emotional and spiritual health of individuals and communities depends on numerous general factors including political conflict and war, literacy, education, employment, adequate housing, poverty reduction and reducing the income gap within countries - in addition to 'good nutrition, hygiene, sanitation and health care interventions'. This means that WHO must partner with other international organisations with many different mandates to promote health. It should also encourage countries to adopt health policies that make it possible for individuals and communities to self-manage; as has occurred with smallpox and polio prevention, iodine supplementation and, in some jurisdictions, smoking and seatbelt usage.
We also recommend that future writings should lessen the focus on 'doctors in their daily communication with patients.' The majority of the world receives health care from other health professionals, community leaders, traditional healers or those with additional knowledge in health, as well as family caregivers,
Finally, we are delighted that this article recommends involving other stakeholders - and recommend that these should be widened past 'patients and lay members of the public' to include community leaders, health organisations and policy makers.
1. Huber M, Knottnerus JA, Green LW et al. How should we define health? BMJ 2011;343:d4163
Competing interests: None declared
Participatory Research at McGill, Canada
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+7 September 2011
We believe that the WHO definition of health is wonderful, and we need to be careful before trying to change it.
We began thinking about this definition this when we asked our eight
MPH students with prior medical degrees if they knew any definition of
health. Only two did, and it was the WHO definition. It seemed unusual
that medical doctors enrolled in public health program did not know what
health was, at least from standpoint of standard definition. Just this
week our Supercourse project (www.pitt.edu/~super1) is likely to reach
over 1 million faculty and students world wide with the definition of
health in various formats, including poster. We shared the definition of
health with 50,000 members of the Global Health Network Supercourse
network and we provided a poster, that can be distributed electronically,
and printed out
http://www.pitt.edu/~super1/globalhealth/What%20is%20Health.htm
Anyone
can distribute this poster, add a link to your website, or print out.
There are several reasons we like the WHO definition.
1. WHO Constitution: The definition of health is in the body of the preamble of the WHO constitution giving it credibility. It is like: "We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America". This obviously is vague, and could have been changed every few years, but it upholds a very important concept, as does the WHO Definition
2. Definition compared to oath: In many ways the WHO definition is an oath or a pledge of allegiance to health. If we use the Hippocratic oath as a framework, despite some aspects being wrong, or hopelessly outdated e.g. "I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:" Despite being outdated, it serves as a pledge to "do no harm" We think the WHO Definition is also an "Oath", pledging the allegiance to improving health and public health.
3. Ten years: We want our students to remember in 10 years that they
were taught the definition of health. In our experience at the University
of Pittsburgh Graduate School of Public Health, most students remember the
WHO definition. BMJ just published a nice paper by Machteld Huber who
argued that the definition of health as the "ability to adapt and to self
manage". http://www.bmj.com/content/343/bmj.d4163.full
While Dr. Huber
provides an excellent overview to make their case, we doubt that this new
definition will be easy to remember
4. Early to bed, early to rise, makes one healthy, wealthy and wise. A litmus test for a definition is to see if we can substitute the definition into health quotes to see if they make sense. If we have correct definition of health, should be usable in different contexts. Existing definition of health is understandable and easy to remember. Should we really try to change it?
We think the WHO definition of health has relevance to the individual and community. The WHO definition, is short, punchy, almost lyrical poetry, with credibility and a wonderful history and sounds much like a pledge. It is an oath to be taken for health and public health. The WHO definition health has stood well for 60 years, as the Hippocrates oath has done the same for 1000s of years. Also, it is like a slogan, "just do it", or "you deserve a break today", that reminds us that we must think of health and physicians should think of prevention. To us, the WHO definition appears to be ideally suited for mass marketing of health.
So this is our rationale. We are driven to the WHO definition of health because of what we want to do, teach all health students about health.
Faina Linkov, Ph.D.
Ronald LaPorte, Ph.D.
University of Pittsburgh Pittsburgh, PA USA
Competing interests: None declared
University of Pittsburgh
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+16 August 2011
Re: How should we define health? Huber et al. BMJ 2011;343:d4163
Huber et al. have proposed to reformulate health as the ability to adapt and self manage. We support the new definition of health with arguments from the fields of occupational health and positive psychology. However, the question is whether or not our health system is able to broaden its scope and get less problem orientated?
As science and technology advance Huber et al. argument that patients with diseases should be helped to adapt and to self manage with their physical, mental and social health. We favor this view from our experiences in the field of occupational health. In the Netherlands occupational physicians not only explore the medical status, but also the disease cognitions, contextual work factors and private life of employees. This helps employees and employers to cope with disease and impairments. One of the key findings is that functioning helps employees to recover from illness, whereas postponing return to work results in reduced health (1). Employees who have difficulties to adapt and manage their diseases and health complaints have high rates of sickness absence, which is of major importance for society (2). Our impression is that employers and the health care system can do more to help employees with chronic illness (3).
Physicians are trained to recognize symptoms of disease and health risks. From the health perspective, it would be worthwhile to pay attention to what makes people healthy. Salutogenesis is the term for studies (4) how people stay well. However, this approach is not very popular in medicine. The same is true for the field of positive psychology. The traditional focus of psychology is on people's weaknesses and malfunctioning, whereas positive psychology proposes a shift towards human strengths and optimal functioning (5). The healthcare system and science are mainly focused on negative prognostic factors. An example of the contrary is that optimism protects against cardiovascular death (6). Another example is engagement; regarding health this is a remarkable determinant of mental health: it protects against burnout and contributes to well being and productivity (7) and is therefore of importance for society. If salutogenesis, optimism and engagement have such health benefits, why not giving positive states a greater role in our health care system?
In the physical, mental and social dimensions of health mentioned by Huber al., we miss the spiritual aspect. They mentioned 'sense of coherence' as a factor for successful coping, which includes enhancing, comprehensibility, manageability and meaningfulness of a stressful situation. This should be worked out. There are studies (8) which show that spirituality, seen in its broad meaning and overlapping with positive psychology, contributes to a sense of mastery and to physical and mental health. Japanese studies (9,10) state that 'ikigai', a Japanese concept meaning something worth living for, contributes to reduced risk of all- cause and cardiovascular death.
Of great importance in developing and implementing this vision, is the ability of the health care system and health care professionals to adapt their clinical outlook. Our difficulties in helping patients with medically unexplained physical symptoms (MUPS), which can only be understood in biopsychosocial context, shows how difficult it is to broaden our scope (11). Evidence (12) from the treatment of patients with longstanding MUPS shows that these patients want to be taken seriously, explanations they understand and this asks other competences, longer but less frequent consultations and that this will result in less medical consumption and better functioning.
To conclude, we acclaim that health should be seen as a ability of patients to self manage disease within their social context, rather than being free of disease or complaints.
References
1 Lambeek LC, Bosmans JE, Van Royen BJ, Van Tulder W, Van Mechelen W, Anema JR. Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a rondomised controlled trial. BMJ 2010;341:c6414.
2 Marmot M, Feeney A, Shipley M, North F, Syme SL. Sickness absence as a measure of health status and functioning: from the Whitehall II Study. J Epidemiol Community Health 2007;1995:49:124-130.
3 Munir F, Randall F, Yarker J, Nielsen K. The influence of employer support on employee management of chronic health conditions at work. J Occup Rehab 2009;19:333-344.
4 Davies P. In praise of salutogenesis: the missing component of most public health work. J Epidemiol Community Health 2008;62:572.
5 Myers DG. The funds, friends, and faith of happy people. Am Psychol 2000;55:56-67.
6 Das S, O'Keefe JH. Behavorial cardiology: recognizing and addressing the profound impact of psychosocial stress on cardiovascular health. Curr Atheroscler Rep 2006;8:111-118.
7 Schaufeli WB, Bakker AB, Van Rhenen W. How changes in job demands and Resources predict burnout, work engagement, and sickness absenteeism. J Organ Behav 2009;30:893-917.
8 Tanyi RA, McKenzie M, Chapek C. How family practice physicians, nurse practitioners, and physician assistants incorporate spiritual care in practice. J Am Acad Nurse Pract 2009;21:690-697.
9 Tanno K, Sakata K, Ohsawa M, Onoda T, Itai K, Yaegashi Y, Tamakoshi A. Associations of ikigai as a positive factor with all-cause mortality and cause-specific mortality among middle-aged and elderly Japanes people: findings from the Japan Collaborative Cohort Study. J Psychosom Res 2009;67:67-75
10 Koizumi M, Ito H, Kaneko Y, Motohashi Y. Effect of having a sense of purpose of life on the risk of death from cardiovascular diseases. J Epidemiol 2008;18:191-196.
11 Ring A, Dowrick CF, Humphris G, Salmon P. What do general practice patients want when they present their medically unexplained symptoms, and why do their general practioners feel pressurized? J Psychosom Res 2005;59:255-260.
12 Hoedeman R, Blankenstein AH, Van der Feltz-Cornelis CM, Krol B, Stewart RE, Groothoff JW. Consultation letters for medically unexplained physical symptoms. Cochrane Database of Sytematic Reviews. 2010 Dec 8: CD006524. Review.
Competing interests: None declared
365 Occupational Health Service
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+15 August 2011
While the response(1) of Shilton et al from the International Union for Health Promotion and Education is correct in pointing out that health is a social product rather than an individual attribute, their proposed definition is unhelpful - its final part is a tautology, which makes the meaningless claim that 'Health is created when... (people's) needs and rights are supported by systems... conducive to better health'. Like the WHO Commission on Social Determinants of Health(2), they also fail to point out that the inequity which as they say, rations global access to health, is a systematic product of the neoliberal capitalism which so dominates global public policies and international relations. We must engage with these realities if we wish to create better health in the world.
I would propose instead a (thus far unpublished) definition of health coined in 1996 by Jane Wills, Nigel Watson and myself: 'Health is a condition in which people achieve control over their lives due to the equitable distribution of power and resources. Health is thus a collective value; my health cannot be at the expense of others, nor through the excessive use of natural resources.' This definition is more in keeping with the WHO's prerequisites for health for all(3) - equal opportunities for all, satisfaction of basic needs (adequate food and income, basic education, safe water and sanitation, decent housing, secure work, a satisfying role in society), peace and freedom from fear of war - and with current perspectives on sustainability.
e-mail: alexss@liverpool.ac.uk
References
1 Shilton TR, Sparks M, McQueen D, Lamarre M-C, Jackson S. The meaning of health - we differ. BMJ rapid response, 8 August 2011.
2 Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization, 2008.
3 World Health Organisation. Targets for Health for All. Copenhagen: WHO Regional Office for Europe, 1985
Competing interests: None declared
Department of Public Health and Policy, University of Liverpool
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+8 August 2011
The meaning of health Trevor Shilton, Michael Sparks, David McQueen, Marie-Claude Lamarre, Suzanne Jackson; (On behalf of the Executive Committee of the International Union for Health Promotion and Education - IUHPE).
Your article by Huber et al (26 July, 2011); BMJ 2011; 343: d4163, quite properly challenges the validity, in the 21st century context, of the WHO definition of health. For the health promotion movement this consideration is particularly pertinent in the year of the 60th anniversary of the founding of the International Union for Health Promotion and Education). The IUHPE is pleased to be able to contribute to the ongoing global conversation on a new definition of health.
A challenge for any new definition of health is to be broad enough to have appeal across sectors, yet not so broad as to become meaningless or unachievable. The meaning of health proposed in the Huber et al article promotes health as a reactive capacity where a threat to health is present. We agree that adaptation and self-management are important qualities for individuals to have when faced with ill health but our definition of health extends beyond the concept of health as a reactive capacity to include concepts of health being both a human right protected by certain entitlements, and health as a resource for life that is affected by social, political, economic and environmental factors.
Public Health has always worked on the premise that changes to these types of environment result in greater health gains than any individual action. Indeed, our ability to 'adapt and self-manage' is applicable only in circumstances that are within our control. Because of inequities, many of the contemporary problems that are the drivers of ill health in low and middle income countries are outside the control of the dispossessed, the poor and the disenfranchised. While we can see the therapeutic approach in which adaptation and self-management are desirable, particularly in wealthy developed countries, we fail to see how this approach offers significant hope to less advantaged populations. Any definition of health must therefore recognise the impact of this fundamental and growing inequity.
To make meaningful differences for those that need them most, we need systems approaches to policy, legislation and environments - not just individual approaches to behaviours. We agree that a fundamental change in addressing health is required, but such change needs to consider underlying determinants that are less amenable to self-management, and consider change to policies and environments. This is the purview of policy decision makers rather than consumers and individuals.
An alternative definition: Health is created when individuals, families and communities are afforded the income, education and power to have control over their lives; and their needs and rights are supported by systems, environments and policies that are enabling and conducive to better health.
We draw your attention to a document from the International Union for Health Promotion and Education (IUHPE) that outlines seven actions that advance health promotion approaches to NCDs. We are pleased to attach a link to this document: http://www.iuhpe.org/uploaded/Activities/Advocacy/IUHPE_KeyMessagesNCDs_...
Competing interests: None declared
International Union for Health Promotion and Education
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+6 August 2011
For general use I think a useful working definition is "the ability to work, love, and sleep" (interpreting the words fairly broadly)
Competing interests: None declared
Northumberland NE613PN
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