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The main objective of the doctor's work, in whatever field he or she functions, is ultimately the restoration and maintenance of health. Yet, as Smith pointed out some time ago, disease and health are ‘slippery concepts’ that we have not been able to define clearly hitherto.1 The difficulty of defining health was clearly illustrated when the distinguished figures of the World Health Organisation (WHO) were asked to undertake this task in 1948. Their response was that ‘health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’.2 Now, a definition should define clearly the nature of a subject as it is or by what effect it has; that is, what it does. In addition, in the fields of science and medicine, it should indicate how the subject is produced and enable it to be measured. The WHO definition did none of these things — it merely took one vague entity ‘health’ and defined it in terms of another equally obscure concept, ‘wellbeing’. It did, however, point out that there was more to health than simply the absence of disease, but this was not really a definition at all, being merely a rather vague description. The waters remained as muddy as ever and the measurement of health was in no way facilitated. Incidentally, the Oxford English Dictionary is no more precise on this subject. It offers a number of meanings including ‘soundness of body, that condition in which functions are duly discharged, spiritual, moral or mental soundness, salvation, well-being, safety and deliverance’ — all parts of the picture, but a real definition is still some way off.
Now one does not have to be Wittgenstein to recognise the absurdity of the situation in which doctors regard health as the main currency of their work, despite the fact that they cannot define exactly what they mean by the term. Indeed, they may even take refuge in the belief that ‘health’ is impossible to define.1 Even more remarkably this extraordinary fact seems of little concern to the medical profession. It certainly did not concern me in any way throughout my entire career. After all, we seemed to manage reasonably well with the current vague concept of what we mean by the term ‘health’. Is this complacency justified? In retirement I have come to think that it is not.
I believe, however, that health can be defined, but for this to be done one has to view the doctor's work from an entirely different perspective. The conventional view of most doctors has, for generations, been reflected by Smith's interpretation of Sydenham's philosophy1 on disease that it had an existence independent of the observer in nature and was ready to be ‘discovered’. In this context, the task of the doctor is primarily (and prior to the start of the 20th century was almost exclusively) the identification and management of disease presented to them by their patients. Of course there were pioneers like Edward Jenner and John Snow in the 18th and 19th centuries who drew attention to the importance of preventive measures and control of environmental forces. However, the profession was slow to learn from them and it was not until the 20th century that preventive care programmes focused on disease, accidents and a variety of other environmental factors likely to affect health. This form of prophylaxis has been developed very slowly and tends to be seen even today as a supplementary back-up service. Thus, disease is the main focus of the doctor's work and the background to disease does not enjoy the same attention, which is why occupational health has only established itself very slowly across the last 50 years while the specialty of rehabilitation has an even shorter lifespan. By contrast, clinical care of diseases and accidents goes back thousands of years. So, I am suggesting that our failure to define health may well have been more influential in the evolution of our philosophy of medical care than, perhaps, we recognised in the past. Philosophers, who claim to be seeking ‘the ultimate nature of reality’, would no doubt point out to doctors that this is precisely what they are failing to do and that their patients are paying the price as a result.
Another side effect of the current view of health is that attempts have been made to classify medical disorders as diseases and ‘non-diseases’, although how one can identify the latter without defining the former is not explained.1,3 It is the failure to be clear in our minds as to what exactly we mean by health that leads us to explore cul-de-sacs of this type.
Supposing, instead of the conventional model, the starting point of our thinking was that men and women live day-by-day in an alien environment subject to a variety of hostile forces, which constantly threaten and sometimes damage them. Their response has been one of Darwinian evolution that enables them, with the assistance of better hygiene, sanitation, diets, health education and medical care, in most cases to adapt to these forces and function normally in the community most of the time — in advanced Western societies at least. Thus, we have a simple definition of ‘health’ as the capacity to make this adaptation, while ‘ill-health’ can be defined as failure to adapt to environmental forces and function normally in society. This approach also enables measurement of health and disease by estimating day-to-day function. The alien forces referred to above are many and varied, but among the more important are accidents, infections, other physical disorders, psychological factors, lack of exercise, poverty, social deprivation, inadequate diet, obesity, poor quality or unsuitable accommodation (including poor heating) and lack of sanitation. To this can be added poor working conditions, inappropriate social behaviour (for example, smoking and drug abuse), ageing, weather conditions, foreign travel, inadequate medical care (either from poor provision or low standards) and the most hazardous sporting or recreational activities. These environmental forces are mainly external but can occasionally be internal when, for example, they take the form of congenital or autoimmune disease.
From this perspective health can be defined, while ill-health and ageing are seen as forms of environmental maladaptation that are obverse sides of the same coin — ‘function’ or more accurately ‘dysfunction’. Of course, although they are fundamentally similar processes, in a number of respects they are quite different from each other. Ill-health is rarely congenital, often acute, sometimes chronic, and during its course it can lead to death in a minority of cases. Ageing is partly genetic and partly environmental, progressive and frequently contributes to death in older people. There is also a clear interrelationship between the two maladaptive processes — disease is much more common in old age and certain diseases, such as progeria and severe unstable diabetes, lead to premature ageing. Ill-health incidentally embraces accidents, disease and syndromes involving less clear cut entities; such as, stress, anxiety, personality disturbance, jetlag and hangovers.
Thus, health and disease can be defined, but how much do we benefit from this clearer understanding of the subject? If this had been our philosophy of medical care in the 19th and 20th centuries, it is a reasonable presumption that control of environmental factors would have received much more attention at an earlier stage than actually happened.
I would also contend that the planning of health care today could be facilitated by the medical profession taking much more account of the context of disease than at present and there are many instances in which this is important. For example, doctors in the UK do far less than they should to halt the carnage on the roads. Of course the profession has to contend with powerful lobbies but where is the logic of having a speed limit of 70 mph and allowing cars on the road capable of twice that speed? A significant minority of the general public are all too often indifferent to this heavy loss of life, as witnessed by their hostility to the introduction of cameras on the roadside that expose their excessive speeding and save lives. The profession should therefore be pressurising the government much more vigorously to take more action in this field.
We should, in addition, be seeking a halt to all advertisements of cigarettes and making it illegal to smoke in places being used by other people (most of them non-smokers) as they have just done in Norway and Ireland. Better education of children in schools about the hazards of smoking, drugs and unprotected sex around the age of 12 years (or perhaps even earlier in some areas) is also required. The Dutch have shown us the way in this field.
It seems to me that, while our standards of clinical care in the UK are, for the most part, high, we lag behind other countries in some areas of preventive care. Neither does research always get the investment it deserves, especially into the environmental factors responsible for disease. It was recently reported that we have one of the highest levels of asthma in the world and this will no doubt lead to the development of more and better antiasthmatic drugs. Of course this is vital, but will it be accompanied by more research into why asthma is so common here? Somehow I doubt that it will get the attention and priority it deserves.
So, if human health is to be seen as a process of adaptation which, with the help of medical care, is improving slowly generation by generation, what is the best way for it to be developed? Surely by making people better equipped to adapt to these hostile environmental forces which, in turn, need to be much better controlled to reduce their harmful effects on human beings. Or, put another way, by the highest standards of clinical care associated with better health education and environmental control. Nowhere is this better seen than in care of the elderly and particularly preventive care in this field. Older people suffer from a variety of medical and paramedical disorders affecting health and sometimes they aggravate the ageing process. Yet, many doctors are doubtful of the value of preventive care at 75 years as there is no firm evidence that it improves health significantly. There is, however, evidence that if the problems of these older people are dealt with earlier and thoroughly they can be kept active and independent for longer and spend less time in institutional care.4 I would contend that these people with, on average, at least three or four medical and para-medical problems affecting health, live in an environment that is increasingly alien as they grow older. The new definition of health encourages doctors to recognise the importance of environmental adjustment in this age group in promoting optimum function.
Likewise, the development of health care services in third world countries, in which environmental forces are much more hostile, would be encouraged by this broad brush approach. Anyone who doubts this need only look at the catastrophic AIDS epidemic in Africa. Surely the WHO should have invested much more money in health education, free condoms and the promotion of better hygiene among prostitutes as soon as the nature of the problem was recognised.
Perhaps it should be made clear that I do not intend to imply that people should lead a risk-free life, since risk is the very salt of life, but rather that they should be protected from environmental hazards to which they are exposed to day by day as they go about their lives.
This different perspective on health defines it's nature and suggests the need for more emphasis on the context of disease than at present, while, at the same time, maintaining the highest standards of clinical care. However, the more we develop the former the less time, energy and money might ultimately need to be devoted to the latter.
If this hypothesis does nothing more than stimulate discussion on the subject of health I shall be happy.
There are two ways of defining something, firstly by saying what it is, and secondly by saying what it is not. In medicine we tend to define health by the second means as, ‘the absence of disease.’ We struggle to raise our perspective towards a more positive concept of what health1 actually is. This leads to the absurdity of consultations in which the doctor says, ‘I cannot find anything wrong with you’ and the patient replies, ‘I can't feel anything right with me!’
I admire Tulloch's bravery in venturing straight into this controversial territory. I think that he has asked the right question and has reached the right conclusion, (healthy individuals in healthy life contexts) but I think he has started from two false assumptions that mean his argument is not as strong as it could be.
First, it is not clear that the restoration and maintenance of health is actually an achievable objective for medicine. Life is a highly prevalent, 100% fatal, sexually transmitted disease. The best medicine can do is postpone the onset of disability and death for short periods. This is a more humble, but more realistic, perspective on the therapeutic endeavour. We do not appear, yet, to have accepted death as a healthy part of life, although Tallis2 gives us some pointers as to how we could do this.
Second, we cannot regard the outside world as ‘alien’ to us. As Merleau-Ponty3,4 describes, we are intrinsically a part of our world, made up from the same components as all the other objects in the world. We are objects in a world of objects. To achieve a successful definition of health we need some idea of ourselves as part of the world, and ourselves as a changing and adapting part of a changeable world.
Mildred Blaxter has looked at these ideas of health.5 Her key themes include health as absence of disease and health as a capacity to adapt and function well. Her final sentence is:
‘The ill person is where he or she always was trying to find a moral identity, trying to live in an uncertain and unreliable body, and trying to make the best of their allotted time in a changing world.’
Ironically this is also exactly what the healthy person is also trying to achieve, albeit from a more pleasant starting point!
I am delighted to find that this article provides another example of a problem that doctors are ‘uniquely well placed’ to tackle: the ‘carnage on the roads’ resulting from cars exceeding speed limits. Perhaps we could all do our bit by walking to work waving red flags to slow the traffic down.
Tulloch sets out to provide some clearer definitions of health and disease but succeeds only in blurring the distinctions between these states. He affirms the familiar doctrine of the New Public Health: health is not a normal state of affairs, but the precarious outcome of a continual individual struggle, requiring eternal vigilance against environmental dangers, constant monitoring of personal behaviour (in matters of diet, exercise, alcohol, smoking and sexual conduct) and a preparedness to submit to regular screening tests and to seek expert medical advice in the cause of the prevention of disease. Indeed, from this grim perspective, illness increasingly appears normal and disease states have become endowed with social prestige — ‘cancer survivor’, ‘recovering alcoholic’ and ‘living with HIV’. The ascendancy of this outlook coincides with epidemics of the ‘worried well’ and a rising tide of invalidity, carrying a heavy cost both for individuals and for society.
Tulloch proposes as a ‘starting point for our thinking’ the notion that we now live in a uniquely dangerous environment, which he characterises as ‘alien’, ‘hostile’, ‘threatening’ and ‘damaging’. This clearly reflects a peculiarly post-modern wounded subjectivity that thrives despite the objective evidence of the uniquely benign character of the environment of contemporary Western societies. Tulloch compounds the confusion by including in his list of ‘alien forces’ jeopardising our health, everything from hazardous sports to ‘physical disorders and psychological factors’ and ‘inappropriate social behaviour’.
All this leads to the endorsement of even more authoritarian and intrusive public health policies — in relation to smoking, and the indoctrination of children — than New Labour has so far introduced.
If this is new thinking about health and illness, bring back the old!