What is health?

In a BMJ editorial in December 2008 Alex Jadad and Laura O’Grady called for a “global conversation” about how we define health (BMJ 2008;337:a2900). This week Jadad and colleagues present the results of that conversation, initiated via a blog on bmj.com to which a good number of you responded (http://bit.ly/r6Usyh), and concluded at a two day meeting in the Netherlands in December 2009 (doi:10.1136/bmj.d4163). They propose a new definition of health as “the ability to adapt and self manage” in the face of social, physical, and emotional challenges.

Why should we be interested in defining health? Because if health is the goal of healthcare and research, we need to know what it looks like and how to measure it. As these articles explain, the currently accepted definition, formulated by WHO in 1948, is no longer helpful and is even counterproductive. Its emphasis on “complete physical, mental and social wellbeing” was radical in its day for stepping away from defining health as the absence of disease. But it is absolute and therefore unachievable for most people in the world. As Richard Smith, one of the authors of this week’s article, pointed out in a BMJ blog, it “would leave most of us unhealthy most of the time” (http://bit.ly/ngzpes). Indeed, the article says that the WHO definition has contributed unintentionally to the medicalisation of society, as more and more human characteristics are recruited as risk factors for disease.

The WHO definition is also unworkable for other reasons, the authors say. In the face of an ageing global population with an increasing burden of chronic disease, it “minimises the role of the human capacity to cope autonomously with life’s ever changing physical, emotional, and social challenges and to function with fulfilment and a feeling of wellbeing with a chronic disease or disability.”

Jennifer Bute provides a moving example of this human capacity. While still practising as a general practitioner she developed the first symptoms of dementia as well as cardiac problems (doi:10.1136/bmj.d4278). Without minimising the challenge of what she has had to endure, her cardiologist comments that coping and adapting were probably easier for her than for others less resourceful and capable. If health is our goal, and if the new definition meets our current realities, the next question is: how can we build and sustain the human capacity to adapt and cope?

Edwin Heathcote is the architecture correspondent for the Financial Times. He describes one approach to maximising human health—the development of “age friendly” cities (doi:10.1136/bmj.d4418). This initiative aims to reverse the trend of removing or excluding older people from active life in cities. How can these people be brought back so that not only they but also the city survive and flourish? The answer, it turns out, is not the current vogue for ramps, big bold signs, benches, and lots of green space.

This week’s articles are the start of six weeks’ coverage building up to the UN summit on non-communicable diseases in September. Other articles will focus on how we should be tackling the key shared risk factors behind the global epidemic of chronic disease—poor diet, alcohol, tobacco, and physical inactivity. As always, we hope for your input via rapid responses on bmj.com.