How should health be defined?
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2900 (Published 10 December 2008) Cite this as: BMJ 2008;337:a2900
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
A person who is healthy is a person who...
...has (right) absolute value to guide his/her discernment in life;
- so that he/she always has sound principle for decision in the face of life uncertainty.(spiritual intelligence)
...do his best in all his/her undertakings;
- achieving personal best potential and be able to take care of self and others. (will and cognitive intelligence)
...think of others when carry on with his/her own life;
- he/she is a prosocial, peacemaker and leader. (emotional intelligence)
...knows how to leave this world; life-purpose knew and achieved.
- so that he/she is always hopeful and not despair. (spiritual intelligence)
Isn't this everyone desires?
Competing interests: No competing interests
Although defining health may be futile, operationalising it is
essential.
We claim that the best operationalisation of health is in terms of
functioning, the key notion of the World Health Organization’s
International Classification of Functioning, Disability and Health (ICF).
The concept of functioning merges two distinct continua: first a
horizontal continuum of discrete categories of functioning arranged in
three dimensions: body functions and structures, activities, and
participation; and secondly, a vertical continuum of degrees of
functioning, from Total Lack to Complete Presence of functioning, which
applies to each category. The categories of functioning are the items
found, and hierarchically arranged, in the classifications that make up
the ICF. Thus, for example, the component of functioning called Body
Functions contains the domain Specific Mental Functions (b1) and, within
this domain, the category Attention Functions (b140). [1]
Why would this complex notion of functioning be suitable as an
operationalization of health? First because the ICF orchestration of
descriptive meanings focuses our attention on the lived experience of
health for an individual in a specified environment. Secondly, presented
as a summary or composite of discrete categories of functioning, the
result shares the basic conceptual features of the notion of health:
Health is a multi-faceted state of a person that ranges over a continuum
from worst health to best health; so too is functioning. More to the
point, functioning is more obviously measureable than health as it is
divisible into categories each of which – visual acuity, muscle strength,
capacity to walk – are standardly measured, or at least are measurable in
principal. As an operationalization of the lived experience of health,
functioning is further useful as it brings to our attention other domains
of human experience (being a parent, being employed, using public
transportation) that are not domains of health as such, but are strongly
affected by states of heath. In the ICF these are called participation
domains, the outcome of interactions between functioning states and
features of the environment, designed to capture the full lived experience
of the person, not merely as a biological but also as a social entity.[2]
References
[1] World Health Organization International Classification of
Functioning, Disability and Health: ICF. Geneva: WHO Publishing; 2001.
[2] Cieza A, Bickenbach J, Chatterji S. The ICF as a conceptual
platform to specify and discuss health and health-related concepts.
Gesundheitswesen 2008; 70: e47-e56.
Competing interests:
None declared
Competing interests: No competing interests
We ought to distinguish between first and third person statements
about health , e.,g., my feeling, and the health specified by a
physician. The two are unbridgeable. Our dilemma originates in third
person statements, however my health is easily defined. It was formulated
by the French physician Leriche:”Health is life lived in the silence of
the organs.”
Unfortunately modern medicine utterly disagrees with this definition
and enforces its third person view on the patient. Accordingly in order to
find out whether one is healthy he has to consult a physician. This
distrust in ones feelings causes unnecessary suffering and breeds the
rising alienation between patients and doctors.
Competing interests:
None declared
Competing interests: No competing interests
We would like to thank the BMJ for opening up a debate on the
definition of health. The Pioneer Health Foundation exists to disseminate
the research of the Peckham Experiment which was a unique enquiry into the
nature of health. This year we have initiated an annual essay completion
open to any students at universities or institutes of higher education in
the U.K., whatever course they are studying (see
www.marylangmanprize.co.uk). The house in which the pilot project started
in 1926 – the Depression - is due to have its blue plaque put up by the
National Heritage at the end of March. There, for sixpence a week, member
families were entitled to the use of a nursery, social club, poor man’s
lawyer, laundry and dress making faculties. (The nearest approach to this
was the first funded Healthy Living Centre, St Augustine’s, at Kings Lynn,
Norfolk)(i).
In return, they agreed to submit what the doctors called ‘the
periodic overhaul’, a thorough medical & dental examination. It soon
became apparent that whatever abnormalities were found were returning in
some form even where they had been successfully treated, on return to the
same environment that had caused them in the first place.
The doctors therefore imagined and built an environment the Pioneer
Health Centre in which they could ‘grow health’ and study the nature of
health as opposed to the treatment of disease. It was this, and a
research that saw families as the focus of the study of health, and the
conflict between the limits of statistics and the assessment of quality,
that precluded funding within the NHS. The Pioneer Health Centre
flourished before the war, was reborn after, and closed in 1950.
This year’s entries to our essay competition will give us a good idea
whether the welcome BMJ discussion of the definition of health is echoed
in the wider academic population.
Ms R.J.H.Fost M.A. Chair, Pioneer Health Foundation.
[Surname corrected to Fost from Frost by BMJ on 9.3.09]
(i) Environment Health Journal October 2000
(ii) Pearse, I. and Crocker , L. (1945) The Peckham Experiment. Routledge
(iii) Gruffudd, P. (2001) '' Science and the Stuff of Life': Modernist
health centres in 1930s London'. Journal of Historical Geography. 27 (3),
395-416.
(iv) Darling , E. (2006) Reforming Britain. Abingdon.
Competing interests:
None declared
Competing interests: No competing interests
In 1948 WHO defined health as “state of complete physical, mental and
social well being and not merely the absence of disease or infirmity” (1).
The definition has given by WHO for health is a theoretical
definition but not operational definition that to it is more philosophical
than scientific(2). In medicine most of the definitions of disease
conditions are operational definitions, i.e., being used to diagnose a
disease. The DEMOCRACY defined as “by the people, for the people, of the
people”. Even after 150 years of democracy definition no country reaches
that stage 100%. Every day intellectuals are suggesting and searching for
new means to reaches that state of democracy but not to change the
definition.
So, when has to change the definition of health? If any invention in
the human biology changes our perception on human health or our
ideological understanding on human health changes, if those perspectives
are not represented in the current definition of health, then only we have
to change the definition. Just based on the reachability /practicability
we cannot change or shorten the definition. For example, the ideal of any
civilized society is “liberty, equality and fraternity”. Is there any
country in which these ideals are achieved 100%? In reality it is merely
possible but still those are the driving ideals for any civilized society.
Is it the definition of health that is hindering to reach universal
health or our lack of clarity on the MEANS? My opinion is, we failed to
reach universal health because of improper, insufficient means. The man is
a social being, but our health interventions are mostly personnel
(medical) in nature and some public health interventions like pure
drinking water, food hygiene and good ventilation etc. Hardly very few
times we address social health through customs and cultural issues in a
society. The human attitudes and behaviors are guided by customs and
culture of that society. We can only change those attitudes and behaviors
by effectively addressing at community level.
Health is not a state to attain for single moment/occasion but it
should be sustainable. Health literacy and health empowerment is at most
need for the sustainable health of an individual and community. School
health programs, health education, social interventions will lead to
health literacy and health empowerment.
1.WHO basic documents. 39th edition 1992
2.Philosophical notes of Norman Swartz on Definitions, dictionaries and
meanings available at http://www.sfu.ca/philosophy/swartz/definitions.htm
Competing interests:
None declared
Competing interests: No competing interests
The works arising from the Pioneer Health Centre in Peckham (www.thephf.org) strongly illuminate this subject. Health is visible in the process of life, not in status at any time. It is the quality of the movement from this moment to the next that counts, and it is independent of present circumstance. Most people of fairly lowly but self-reliant means are healthier than the very wealthy who could not boil an egg, or fear to walk the streets without a bodyguard.
Peckham defined health as the faculty for mutual synthesis with one's environment. I would suggest a simpler version - health is the ability to participate in creation (or constructive activity).
By this definition, most of us are healthy most of the time. Doctors study how empty the glass may be: health practice would wish to know how full. Having made a modest career of health practice these last 30 years I know that it is quite different from medicine, but can rapidly reduce demand for medicine - by up to a half, in my experience. It reduced my personal prescribing to under half the national average (PACT figures).
Whether we are yet ready to expand our vision this much, remains to be seen. I doubt if the initiative will come from within the field of medicine. Examples of good health practice crop up everywhere in education projects and social enterprises, nevertheless. Economic and climatic constraints will force healthy living on us eventually, or we shall perish.
Competing interests:
None declared
Competing interests: No competing interests
This is the Year of Sanitation.
Separating water from sewage was the greatest achievement of the mid
19th century yet 40% of the world's population still do not benefit from
this capability.
The BMJ reported that ALL could have had effective toilets for 1/9th
of what was spent on bailing out the bankers.
Why bother defining what health is when this is how the global
community behaves.
Competing interests:
None declared
Competing interests: No competing interests
Measuring health was a topic (Chapter Two) of one of the earliest
Global
Health Reports (World Health Organization, Geneva, 1998). This Report
includes the first published survival curves for humankind. These show a
striking upward push of the survival curve from 1955 to 1975 to 1995.
The curves summarise the global transformation from unhealthy to
healthy
society that began to take effect in the 20th century. Viewed globally,
succeeding birth cohorts progressed through the lifespan with ever
decreasing deaths during childhood, adolescence and adulthood. It is from
the type of survival curve, which the WHO Report depicts, that life
expectancy
values for different ages are calculated. Between 1955 and 1995, life
expectancy at birth increased globally from 48 years to 65 years. Despite
the
unequal rates of progress between geographic regions, this is a measure of
the success of planet-wide survival.
The Title of the 1998 Report was Life in the 21st century and it
states that
efforts are under way, 'to develop indicators of positive health such as
health expectancy and its variants'. This is to say, WHO anticipates that
advances in health in the present century will be measured by healthy
survival. Death does not necessarily have to be the only exit measured.
Life tables have been in use for three centuries. They measure
survival in an
elegant way. The summary survival statistics derived from the life table
are
widely understood by lay people.
The WHO Global Health Report for 2004 published healthy life
expectancy
(HALE) estimates for all WHO Member States.
Competing interests:
Former WHO staff member
Competing interests: No competing interests
Although a "Rapid Response" is the usual way to share personal views
about interesting articles with others, we would like to invite readers to
make their contributions on the definition of health through the blog we
have set up at: BMJ blogs.
We would also appreciate if the rapid responses that have already
been written here could be copied into the blog. In this way, they could
become part of a much more dynamic exchange of ideas.
The process is just as simple.
Thanks for your support.
Competing interests:
None declared
Competing interests: No competing interests
Re: How should health be defined?
“Health is state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. This is the current definition of health according to the World Health Organization. This definition is one that is very political. There are many important aspects of life that constitute as being healthy for a lot of individuals, such as spirituality, that are being left out of the definition. Health as defined by the WHO is biased. The individuals who came up with this definition are probably well off and lack the experiences and burdens of the people whom they are defining health for. For example when someone has money they can afford better healthcare and have the opportunity to catch disease or any other type of sickness in its early stage. Therefore this person still has the chance to live a normal healthy life. On the other end of the spectrum, someone who has a low income is unlikely to visit a doctor on a routine basis, which can result in an unhealthy lifestyle. Health education is lacking or completely absent in some populations. Educating people about how to live a healthy lifestyle can prevent them from making unhealthy decisions, such as smoking.
The current definition of health is very vague. Many people will have many different interpretations of the current definition. Social-well being differs from person to person and especially between different age groups. Social-well being to a teenage could mean being able to fit in with the crowd. Social-well being needs to be defined in more detail and must include happiness. Happiness is what most people strive for in life, and this definition doesn’t include it. Being happy has the power to change how someone feels drastically.
Health cannot be easily defined, but the current definition lacks a lot of important aspects of life that are considered detrimental to well being, such as education, financial status, and happiness. The definition needs to be updated to include these important factors.
Competing interests: No competing interests