A new definition of the multifaceted concept of health
25 MINUTE READ
This article arises from Anthony’s extensive expertise around the globe encompassing health work in many cultures. He proposes a new definition of the multifaceted concept of HEALTH and seeks a greater understanding of the inter-related environments that determine the health status of individuals and groups.
Health like love and pain are difficult to define but that makes them no less real.
Health comes from the Old English word hal or hale meaning ‘whole’. Health (Anglo-Saxon) is the condition of being safe, sound and whole. It is the same concept of health that is encapsulated in the Hebrew word, Shalom. This adds a special dimension in a religious context to the question; ‘Would you prefer to be cured’ or ‘made whole’ (Mark 2:8-12). The People’s Charter of Health sets out health with a secular perspective as a ‘social, economic and political issue and above all a fundamental human right’.
There are many definitions and perceptions of health that have been proposed over the past 2500 years, probably longer. Undoubtedly the most well-known of these is that put forward by the World Health Organisation (WHO) in 1946-7, namely, that:
‘Health is a state of complete mental, physical and social well-being, and not merely the absence of disease and infirmity’.
A potpourri of definitions of Health:
…a condition or quality of the human organism which expresses adequate functioning under given genetic and environmental conditions. (WHO, 1957)
…that state of moral, mental and physical well-being which enables a person to face any crisis in life with the utmost grace and facility. (Pericles, C5 BC)
…the state in which the individual is able to mobilise his or her resources – intellectual, emotional and physical – for optimum daily living. Encyclopaedia of Educational Research, National Education Association, (USA)
…that quality resulting from the total functioning of the individual that empowers him to achieve a personally satisfying and socially useful self. (E B Johns, source unknown)
…not a state, but a potentiality – the ability of an individual or social group to modify himself or itself continually, not only in order to function better in the present but also to prepare for the future.
…physical, intellectual and emotional performance which is acceptable to the individual or to society. (Maddocks I & Maddocks D, 1978)
…wholeness – it is the complete integration and perfect functioning of body and mind maintained throughout every phase of activity. (Maharishi Mahesh Yogi)
Whatever is eaten, unless there is rice, there is no life in the body.
…assured more by an orderly life and wise behaviour at the table than by those boxes with long, beautiful and mysterious names in the shops of the apothecaries. (Francesco Redi, born 1926)
…a positive state of being able to do the things they enjoy, and participate in meaningful social relationships. (Baxter M 1991 in Labonte R. International Perspectives on Healthy Communities.)
Health is the power to live a full adult living life in contact with what I love – the earth and the wonder thereof – the sea, the sun – I want to be all that I am capable of becoming. (Katherine Mansfield quoted by Rene Dubois.)
Health designates a process of adaptation. It is not the result of instinct, but an autonomous yet culturally-shaped reaction to socially created reality. It designates an ability to adapt to changing environments, to growing up and to ageing, to healing when damaged, to suffering and peaceful expectation of death.
Health embraces the future as, and therefore includes anguish and inner resources to live with it. (Ivan Illich, Medical Nemesis).
Health as a normal condition of the body does not mean absence of disturbance but rather an effective bodily reaction toward them which continuously re-establishes the precarious equilibrium between different physiological functions. (H.P. Drietzel).
Health is the natural order of things and a positive attitude to which men [and women] are entitled if they govern their lives wisely. (Rene Dubos, 1959)
The original 1947 WHO definition was very restricted, and expresses a kind of utopian wish, perhaps coming so
soon after the Second World War. As expressed, almost none of us ever achieve such a state and therefore the definition has very limited use. For example, an amputee who has adjusted to his or her state can certainly be ‘healthy’, even if they have a persisting disability or handicap. Similarly, a community can be said to be healthy with minimal but adequate material resources, such as some of the Pacific islands.
Two important dimensions in considering a definition of ‘health’ include, firstly, the level of containment or control of any pathological process such as hypertension or diabetes, or level of rehabilitation of an injury, such as that following an amputation and, secondly, how well the individual or group relates to those conditions.
Much less well known is the revised WHO definition put forward a decade later, and which added the importance of environmental conditions in determining health status. The original WHO definition may have been based on that put forward by the Greek philosopher Pericles in the 5th century BC, but Pericles specifically identifies that effective functioning with ease is an essential component of good health.
WHO again revised its definition in 1998, at last recognising the importance of the ‘spiritual’ component which was incorporated into the 1947 version. This recognises that the patient or their community recognises a spiritual dimension to their lives irrespective of what their health professionals and the society around them believes. And
I would add that failure to take this into account may fail to provide the template required for their best pathway of care.
I have developed a new definition of health which identifies its major components, and which can be considered from both an individual
and a group or community perspective
HEALTH is the level to which, as individuals and groups, we can adapt to and live in harmony with, the inter-related spiritual, mental (or personal), social, physical, chemical and biological environments, in which we live, work and recreate, without disease and without dis-ease. (Radford 1979).
This definition can be illustrated (Figure 1).
Various societies and cultures may have very different perspectives on what are the criteria for a healthy individual or community. This is illustrated in the table below.
In summary, the present western-based health delivery practices are predicated on the values of secular-definition, specialisation, and individualism. This is often in opposition to many communities whose values are more holistic, familial, and spiritually embraced (Look, M. et al. Pacific & Health Dialog, 5(2): 296, 1998).
The following photograph illustrates the social significance of conditions such as head lice, which in some communities of Papua New Guinea and of Australian Aborigines is not necessarily regarded as an illness.
Illness and Disease
There are also numerous definitions of illness and disease that are often as imprecise as those of health.
An ILLNESS is a state of the organisation that fulfills the requirements of an appropriate reference group for admission to the sick (and sometimes other, e.g. criminal), role. It is not, per se, sickness. (An appropriate reference group is the social group most able, most willing or both, to underwrite the social cost of the sick role). (I Pilowsky, Adelaide). See also Maddocks & Maddocks definition of health above.
SICKNESS has been found to be a relative state [and like ‘health’] capable of almost infinite interpretation by both potential patients and the medical profession. (M. Cooper in M Perlman, The Economics of Health and Medical Care, 1974, p.105)
A DISEASE is a series of clinical appearances found in association with special morbid anatomical, biochemical and physiological findings, but presents us with the dilemma of ‘at what point in a continuously variable parameter do we leave normality and pass to abnormality’? (H Dudley, 1969) For example, when does blood pressure become high enough to be labelled hypertension?
Figure 2 is a summary.
The above is very much ‘a medical model’ of disease that does not address the issues of ‘social lesions’. In its concentration on the political determinants of health the People’s Charter for Health identifies ‘inequality, poverty, exploitation, violence and injustice’ as the root causes of ill health and death, especially for the poor and marginalised.
The International People’s Movement for Health believes that globalisation and war are currently the major social determinants of ill health. For example, UNICEF identifies that over half a million children deaths resulted from the sanctions imposed on Iraq after the Gulf War in the 1990s.
HEALTH is not something one does or does not have.
• Health is a level, that is, it is a state that may change from day to day or month by month. It is not something of which you have ‘all’ or ‘none’. It is a dynamic or changing state. You may be very healthy today, able to function well and with joy, but tomorrow you may develop pneumonia, or exhibit tinea or schizophrenia, or feel depressed. The same may be true of your family, workplace or community. An individual may be ‘healthy’ but their family, church, soccer team or community may be quite ‘unwell’.
• Health relates both to individuals and to groups. And the level of health exhibited by one person may well affect the level of health of others, either positively or negatively.
We all belong to several groups: family, office, football team, church or religion, class, bingo club, village and city, even nation. Any of these groups may be dysfunctional – ‘unhealthy’. Clearly, if the family is functioning well, the individuals in it are much more likely to feel good about life and themselves, and conversely, if the family is dysfunctional then that is more likely to alter the state of health of its individual members. During the 1990s there was a strong movement which extended this concept to addressing the issue of ‘Healthy Cities’ and later ‘Healthy Islands’. And if one can have healthy cities, nations and islands you can have unhealthy ones, for example, the social ill-health on Pitcairn Island, the unhealthy Nauru Islanders with their very high level of Type 2 diabetes, or Scotland and its level of ischaemic heart disease compared with other western nations.
• Health is fundamentally about adaptation. Health status is the outcome of a number of stresses to which the human organism or group is subject; from conception to consolation (death). How well we adapt to these stresses determines our level of health. This will depend in part on the level of stress and its rate of change and our capacity to adapt to it.
• Health presupposes some level of harmony or contentment, expressed so well by Pericles in his definition quoted above. Health is not a matter of mere existence.
• Health is essentially environmentally determined. There are at least six readily identifiable categories of environment – spiritual, mental (or personal), social, physical, chemical and biological. These environments are variously inter-related with each other in the expression of any illness or disease state. Each of these six environments can be further subdivided into a number of component parts, which are also variously inter-related. See below.
• Health relates to what we do – living, working or in recreation.
• By comparison, ill health expresses itself in either disease or dis-ease.
These six inter-related environments can almost all be changed, either by the action of an individual, or by society or its groups e.g. by consensus, by committee or by law or lore. For example, by personal or group consensus or committee decisions, or it may be enshrined in legislation such as tobacco, food and road safety issues. The age, sex and hereditary components of the biological environment, while discrete variables, are virtually unalterable, and all the other components impinge on them in an interactive manner.
The outcome of these interactions determines whether we are ‘healthy’ or ‘illthy’.
• what I eat, drink and breathe,
• whether or not I am able to control any other disease variables associated with, say, heart conditions, such as high blood pressure and diabetes, levels of blood fats, and
• whether or not I exercise, smoke or can successfully adapt to the level of stress to which I am subjected, whether I have a family history of high cholesterol, and certain gene patterns know to be associated with ill health.
• all influence whether or not I have a coronary life disease or a cardiac death.
These factors interacting may have more influence on my ‘heart health’ than the fact that I am a middle-aged male with a family history of heart disease, even though all of the above factors are risk factors per se for heart disease. Figure 3 illustrates this.
Let us look in more detail at these inter-related environments that determine our health status.
The spiritual environment
D’Souza (2001) says that “spirituality is the generator that sources the energy within and enables a person to search for meaning through connections with the environment and in relationships. It represents ‘a dialogue within ourselves’ through which we weigh up the meaning of our life – visible and invisible – past, present and future.”
Most people believe in the power of the spiritual world to influence in some way the state of health of individuals or groups. WHO now recognises that most, probably all, cultures have a set of spiritual beliefs held by a varying proportion of their populations.
Spirit worlds may have both ‘good’ and ‘bad’ dimensions. For example, to Christians the Holy Spirit empowers the work of God for good and Satan with all his spirits, seeks to throw chaos into the world.
‘Every Christian would agree that a man’s spiritual health is exactly equivalent to his love for God’ (C.S. Lewis, The Four Loves, Collins, 1960, p.8).
To the animist, there are also good and bad spirits – of fertility and the forest, gardens, rivers and fields. It is believed that Health exists when there is joyful conforming to the will of God and ‘binding’ Satan in the case of the former, and successfully placating or appeasing those of the latter groups.
Irrespective of their own belief system, health care workers working in a culture or subculture different from their own, need to gain an understanding of the spiritual world of the communities in which they work, and the ways they believe it may influence their lives.
Their beliefs may significantly determine whether or not they will seek care (e.g. abortion), comply with advice (e.g. control smoking or drinking), or undertake medication (e.g. immunisation) or surgery (e.g. Jehovah’s Witnesses).
The mental (or personal) environment
This environment relates to how I feel about myself and others – our relationships. Its components include the psychological and emotional states which interact with each other, and with our state of being: for example, the level of tiredness; or hormonal state – pre-menstrual, pregnancy, menopause; employment status; family harmony and so on. And here we can identify the potential influence of the biological and social environments on the mental one.
The social environment is perhaps the most important category when considering health services and their effect on health status, both of groups and individuals.
Like other environments, the social environment has a very complex and interactive set of component parts.
Example 1. Whether an individual or community uses technologies for child spacing depends firstly on their knowledge of methods and their capacity to access or purchase the method of their choice. The availability of the technologies relates not only to knowledge and cost but also to religious beliefs, political legislation and professional attitudes (and skills, for example, ability to perform a sterilisation procedure), local customs and beliefs.
Example 2. Whether or not an individual smokes relates not only to availability of tobacco products, but also to the consequences – cost, political constraints such as tax, advertising, laws regulating use in public places, wages, efforts to influence our choice by health professionals, peer pressure, family environment and so on.
The potential interaction of these first three ‘environments’ and their relationship to health status is well demonstrated in the perception of ill-health of much of the developing world. Professor Ogunlesi of Nigeria stated many believe that ill-health is related to a ‘disturbance of relationships between individuals or groups, or between an individual or groups and the supernatural’. Increasingly in industrial societies, we are recognising that disturbances in relationships are a major factor in the incidence and prevalence of illness, both mental and physical (e.g. depression, RSI, PTSD).
Example 3. Poverty of itself is not an absolute correlate with ill-health, for example, of Cuba and the state of Kerala in India, both of whose populations are very poor. However, both have high levels of education and a political system which promotes equity of access to services such as health and education. Kerala, although one of the poorest states of India has one of the highest standards of education and best set of health indicators – it is also the most communist and holds the highest proportion of Christians!
The physical environment
The effects of temperature: burns (water, steam, sun, frost, and electricity) and radiation (cataracts, skin and other cancers) are obvious. Interactive with the physical environment and many skin cancers is the genetic component of the biological environment, comparing white and dark-skinned races and family genotypes. Less obvious are those influences resulting from high barometric pressure: the bends in divers and low pressure: altitude sickness in mountain climbers. Adaptation has a major role in the expression or otherwise in many of these conditions (e.g. the story of frog and its response to water of different temperatures)
The chemical environment
The chemical environment includes what we eat, drink, inhale, and absorb through the skin. Fluids may contain elements positive for health, such as adequate but not excessive levels of fluoride, low levels of alcohol and iodine, or negative ones including toxins such as arsenic, mercury, alcohol or lead.
Our food has many items such as water, vitamins, protein, fats and carbohydrates as well as essential elements such as iodine and iron. A correct balance is essential for health, while deficiency and excess can both cause disease, e.g. Vitamin A. Similarly, our diet may contain potential elements that can damage health e.g. high saturated fat or low fibre intake.
The biological environment has two major subgroups: the external and internal.
The external environment includes organisms which may cause illness (such as viruses, bacteria and protozoa), the animals which can inflict injury (such as crocodiles and snakes) or transmit illness, such as mosquitoes and parasitised sheep, pork, prawns and fish.
The internal biological environment has three components, which we cannot change, namely, age, heredity (well, almost!) and gender (though some try), but also consists of our immunological state (due to gene patterns, immunisation, previous disease and nutritional status), current medication and to various pathophysiological conditions that we may have, such as diabetes or hypertension.
These internal and external states interact with each other and with other environments. For example, if you have had designer influenza immunisation (a chemical), you will probably be immune (internal environment) from this year’s flu virus strain (external biological environment). If you do not know about influenza vaccine or cannot afford it, or the government does not supply it (education and economic and political components of the social environment), then your health is at risk, as is that of the rest of the community, as the level of population (herd) immunity will be reduced with low immunisation coverage, thereby increasing the risk of disease and death to others, especially the very young, elderly people and those who are immuno-compromised.
Let us look at the cultural aspect of the Social Environment in a little more detail.
Each society has differing beliefs which may be positive or negative with respect to health. They may be related to anthropological or sociological factors, which in turn may be derived from the dominant culture, one of its minority cultures, or from any of the subcultures within them (eg social behaviour of some bikie and age-specific groups. Perceptions of health and illness are a major issue when it comes to advocating beneficial behaviour change to an individual (such as encouraging exercise or wearing a crash helmet or seatbelt) and to minimise risk of a behaviour (such as weanling diets). Perceptions are also important when encouraging a population to access health services and adopting health behaviours likely to improve or reduce health status.
Time is an important factor in changing health behaviours in groups (e.g. smoking, cost). The whole area of consequences and benefits may be important.
Examples include criteria for seeking or not seeking care, such as the age, gender or ethnic or social group of the health worker and their attitude to traditional healers or complementary medicine or beliefs by individuals or groups regarding the capacity of the health service to manage a particular condition such as goitre or cataracts, or the value of alternative or complementary medicine. Smoking or not smoking, or the chewing of betel nut or eating a particular food may be forbidden by either a religion or group pressure, and societal norms may be formulated by legislation (e.g. vitamin-enriched foodstuffs). For example, among Adventist, Muslim, or Jewish groups, there is no incidence of pork-related diseases such as Taenia solium or trichinosis. In countries where there is a high level of education, this can be used to influence legislation aimed, for example, at tobacco and iodine-related diseases, fluoride in toothpaste and traffic injuries and use of helmets or seatbelts as evidenced by the falling incidence of the prevalence of tobacco-related diseases. Motor vehicle accidents and those with iodine deficiency have been reduced. Varying eating patterns in one cultural group such as fat intake may result in marked differences in disease such as in the gradient of ischaemic heart disease incidence among the Japanese in Japan, Hawaii and California.
Such changes are not exclusively related to the use or non-use of a particular aetiological agent such as tobacco or fatty foods, but may include changing the coverage of a preventive measure such as exercise or immunisation. Change may also be the result of participation rates such as in screening for diabetes or hypertension followed by the use of effective and acceptable remedies such as hypertensives for high blood pressure. Many of these interventions may be multiple and interactive, such as those which have contributed to the decline in ischaemic heart diseases and stroke incidence rates in industrialised countries.
Cultural patterns which are positive for health can be used by health workers to encourage other healthy behaviours such as breast-feeding, or ensure that there are female health workers as well as male in Muslim societies. Where foreign health workers are used, such preclusions for attendance may be acceptable. Behaviours may also be bad for health and need to be discouraged. Some examples of such behaviours would include female circumcision, rubbing dirt on the birth cord stump, and the prohibition of certain nutritious foods especially for women and children.
With respect to its health value, any particular behaviour or custom may be:
i) good: such as breast feeding and care of the elderly.
ii) bad: such as rubbing dirt or dung on the birth cord stump, or smoking cigarettes.
iii) neither good nor bad: such as pre-chewing food for babies, the gypsy custom of placing an onion in a sock to treat fevers or wearing a copper bangle to help arthritis.
iv) both good and bad: for example, low and excess alcohol use.
v) not known.
Those that can be identified as ‘neither good nor bad’ may be so only while the wearer is not compromised. For example, the lucky charms or talismans that are common in many cultures and usually worn around the neck may be harmless in themselves, but are not so if they delay seeking care for significant conditions. The charm needles or susuks of Malays are inserted subcutaneously into the face and chest. They may or may not have a spiritual significance. Copper and other types of bracelets to ward off arthritis also fall into this category.
The good can be used to affirm a cultural trait that is good for health such as breastfeeding and used as a basis for changing those behaviours that are detrimental for health. We can observe those behaviours whose value we don’t know until we can place them in another category. For ‘foreign’ health care workers, it is a good idea to establish a file of different health behaviours, to which you can refer in developing new programs, and leave as a record so that the person who follows does not have to start again from the beginning.
Failure to pass on acquired knowledge may have undesirable health outcomes. In the Oro Province of Papua New Guinea, people believe that the milky sap from the skin of the pawpaw (papaya) that irritates the human skin is the cause of scabies. Without knowing about this local belief, foreign public health nurses working in the area, tried to encourage the use of pawpaw as a weaning food because of its high content of vitamins A and C. The mothers attending the clinics admonished their daughters, who were used as interpreter nurse aides, ‘You know papaya causes scabies, maybe the other stories you are telling us are equally stupid!’
Thus, health is a multidimensional concept which can be influenced both positively and negatively in the incidence and prevalence of disease. The health worker, the community and politicians need to develop an understanding of how the many components of the environment can be changed to improve the health and quality of life of individuals and groups.
Looking back through some old papers I came across the following which a student produced in a class exercise exploring definitions of health at a YWAM School of Primary Health Care in Perth in 2000. I think it is the most succinct description of health I have found. “Health is the expression in body, mind, and spirit as God meant us to be.”
Prof Anthony Radford Emeritus Professor Anthony J Radford AM has been a long-time member and was formerly national chairman of CMDFA and an international vice-president of ICMDA. He completed undergraduate training in Adelaide in 1969 and postgraduate study at the Universities of Liverpool, Edinburgh and Harvard. He has undertaken health work in 45 countries working with WHO, UNICEF, the World Bank, World Vision International and numerous NGOs in areas of Primary Health Care, especially in Maternal and Child Health. His also worked as a rural locum GP in remote and isolated South Australia. He has two autobiographies, namely Singsings, Sutures and Sorcery and Have Stethoscope, Will Travel. He has been a long-time member and formerly national president of CMDFA and an international vice-president of ICMDA.
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D’Souza R (2000). Spirituality and religiosity – has it a place in psychiatric assessment and management? Dept of Rural Health. Broken Hill, NSW.
Hiebert, PG. Anthropological Insights for Missionaries. Baker: Grand Rapids. 1987.
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Radford AJ & Harris RD (1986). Specific Strategies in Health Education. Hygie V:38-44.