How Should We Define Health? BMJ PDF

BMJ: first published as 10.1136/bmj.d4163 on 26 July 2011. Downloaded from http://www.bmj.com/ on 16 July 2024 at Queen Margaret University Consortia...

BMJ: first published as 10.1136/bmj.d4163 on 26 July 2011. Downloaded from http://www.bmj.com/ on 16 July 2024 at Queen Margaret University Consortia. Protected by copyright. BMJ 2011;343:d4163 doi: 10.1136/bmj.d4163 Page 1 of 3 Analysis ANALYSIS How should we define health? The WHO definition of health as complete wellbeing is no longer fit for purpose given the rise of chronic disease. Machteld Huber and colleagues propose changing the emphasis towards the ability to adapt and self manage in the face of social, physical, and emotional challenges Machteld Huber senior researcher 1, J André Knottnerus president, Scientific Council for Government Policy 2, Lawrence Green editor in chief, Oxford Bibliographies Online—public health 3, Henriëtte van der Horst head 4, Alejandro R Jadad professor 5, Daan Kromhout vice president, Health Council of the Netherlands 6, Brian Leonard professor 7, Kate Lorig professor 8, Maria Isabel Loureiro coordinator for health promotion and protection 9, Jos W M van der Meer professor 10, Paul Schnabel director 11, Richard Smith director 12, Chris van Weel head 13, Henk Smid director 14 1 Louis Bolk Institute, Department of Healthcare and Nutrition, Hoofdstraat 24, NL-3972 LA Driebergen, Netherlands; 2Department of General Practice, Maastricht University, Scientific Council for Government Policy, Postbus 20004, NL-2500 EA The Hague, Netherlands; 3Department of Epidemiology and Biostatistics, School of Medicine, University of California at San Francisco, USA; 4Department of General Practice, VU Medical Center, Amsterdam, Netherlands; 5Centre for Global eHealth Innovation, Toronto General Hospital, Toronto, Canada; 6Department of Public Health Research, Wageningen University, The Hague, Netherlands; 7Pharmacology Department, National University of Ireland, Galway, Ireland; 8Stanford Patient Education Research Center, Palo Alto, CA, USA; 9National School of Public Health/New University of Lisbon, Portugal; 10General Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands; 11Netherlands Institute for Social Research, The Hague, Netherlands; 12 UnitedHealth Chronic Disease Initiative, London, UK; 13Department of Primary and Community Care, Radboud University Nijmegen Medical Centre; 14Netherlands Organisation for Health Research and Development, The Hague, Netherlands The current WHO definition of health, formulated in 1948, system. New screening technologies detect abnormalities at describes health as “a state of complete physical, mental and levels that might never cause illness and pharmaceutical social well-being and not merely the absence of disease or companies produce drugs for “conditions” not previously infirmity.”1 At that time this formulation was groundbreaking defined as health problems. Thresholds for intervention tend to because of its breadth and ambition. It overcame the negative be lowered—for example, with blood pressure, lipids, and sugar. definition of health as absence of disease and included the The persistent emphasis on complete physical wellbeing could physical, mental, and social domains. Although the definition lead to large groups of people becoming eligible for screening has been criticised over the past 60 years, it has never been or for expensive interventions even when only one person might adapted. Criticism is now intensifying,2-5 and as populations age benefit, and it might result in higher levels of medical and the pattern of illnesses changes the definition may even be dependency and risk. counterproductive. The paper summarises the limitations of the The second problem is that since 1948 the demography of WHO definition and describes the proposals for making it more populations and the nature of disease have changed considerably. useful that were developed at a conference of international health In 1948 acute diseases presented the main burden of illness and experts held in the Netherlands.6 chronic diseases led to early death. In that context WHO Limitations of WHO definition articulated a helpful ambition. Disease patterns have changed, with public health measures such as improved nutrition, hygiene, Most criticism of the WHO definition concerns the absoluteness and sanitation and more powerful healthcare interventions. The of the word “complete” in relation to wellbeing. The first number of people living with chronic diseases for decades is problem is that it unintentionally contributes to the increasing worldwide; even in the slums of India the mortality medicalisation of society. The requirement for complete health pattern is increasingly burdened by chronic diseases.7 “would leave most of us unhealthy most of the time.”4 It Ageing with chronic illnesses has become the norm, and chronic therefore supports the tendencies of the medical technology and diseases account for most of the expenditures of the healthcare drug industries, in association with professional organisations, system, putting pressure on its sustainability. In this context the to redefine diseases, expanding the scope of the healthcare Correspondence to: M Huber [email protected] Reprints: http://journals.bmj.com/cgi/reprintform Subscribe: http://resources.bmj.com/bmj/subscribers/how-to-subscribe BMJ 2011;343:d4163 doi: 10.1136/bmj.d4163 Page 2 of 3 ANALYSIS BMJ: first published as 10.1136/bmj.d4163 on 26 July 2011. Downloaded from http://www.bmj.com/ on 16 July 2024 at Queen Margaret University Consortia. Protected by copyright. WHO definition becomes counterproductive as it declares people post-traumatic stress disorders.12 13 The sense of coherence with chronic diseases and disabilities definitively ill. It includes the subjective faculties enhancing the minimises the role of the human capacity to cope autonomously comprehensibility, manageability, and meaningfulness of a with life’s ever changing physical, emotional, and social difficult situation. A strengthened capability to adapt and to challenges and to function with fulfilment and a feeling of manage yourself often improves subjective wellbeing and may wellbeing with a chronic disease or disability. result in a positive interaction between mind and body—for The third problem is the operationalisation of the definition. example, patients with chronic fatigue syndrome treated with WHO has developed several systems to classify diseases and cognitive behavioural therapy reported positive effects on describe aspects of health, disability, functioning, and quality symptoms and wellbeing. This was accompanied by an increase of life. Yet because of the reference to a complete state, the in brain grey matter volume, although the causal relation and definition remains “impracticable, because ‘complete’ is neither direction of this association are still unclear.14 operational nor measurable.”3 4 Social health Need for reformulation Several dimensions of health can be identified in the social domain, including people’s capacity to fulfil their potential and Various proposals have been made for adapting the definition obligations, the ability to manage their life with some degree of health. The best known is the Ottawa Charter,8 which of independence despite a medical condition, and the ability to emphasises social and personal resources as well as physical participate in social activities including work. Health in this capacity. However, WHO has taken up none of these proposals. domain can be regarded as a dynamic balance between Nevertheless, the limitations of the current definition are opportunities and limitations, shifting through life and affected increasingly affecting health policy. For example, in prevention by external conditions such as social and environmental programmes and healthcare the definition of health determines challenges. By successfully adapting to an illness, people are the outcome measures: health gain in survival years may be less able to work or to participate in social activities and feel healthy relevant than societal participation, and an increase in coping despite limitations. This is shown in evaluations of the Stanford capacity may be more relevant and realistic than complete chronic disease self management programme: extensively recovery. monitored patients with chronic illnesses, who learnt to manage Redefining health is an ambitious and complex goal; many their life better and to cope with their disease, reported improved aspects need to be considered, many stakeholders consulted, self rated health, less distress, less fatigue, more energy, and and many cultures reflected, and it must also take into account fewer perceived disabilities and limitations in social activities future scientific and technological advances. The discussion of after the training. Healthcare costs also fell.15 16 experts at the Dutch conference, however, led to broad support If people are able to develop successful strategies for coping, for moving from the present static formulation towards a more (age related) impaired functioning does not strongly change the dynamic one based on the resilience or capacity to cope and perceived quality of life, a phenomenon known as the disability maintain and restore one’s integrity, equilibrium, and sense of paradox.17 wellbeing.6 The preferred view on health was “the ability to adapt and to self manage.” Measuring health Participants questioned whether a new formulation should be called a definition, because this implied set boundaries and The general concept of health is useful for management and trying to arrive at a precise meaning. They preferred that the policies, and it can also support doctors in their daily definition should be replaced by a concept or conceptual communication with patients because it focuses on framework of health. A general concept, according to sociologist empowerment of the patient (for example, by changing a Blumer,9 represents a characterisation of a generally agreed lifestyle), which the doctor can explain instead of just removing direction in which to look, as reference. But operational symptoms by a drug. However, operational definitions are definitions are also needed for practical life such as measurement needed for measurement purposes, research, and evaluating purposes. interventions. The first step towards using the concept of “health, as the ability Measurement might be helped by constructing health frames to adapt and to self manage” is to identify and characterise it that systematise different operational needs—for example, for the three domains of health: physical, mental, and social. differentiating between the health status of individuals and The following examples attempt to illustrate this. populations and between objective and subjective indicators of health. The measurement instruments should relate to health as the ability to adapt and to self manage. Good first operational Physical health tools include the existing methods for assessing functional status In the physical domain a healthy organism is capable of and measuring quality of life and sense of wellbeing. WHO has “allostasis”—the maintenance of physiological homoeostasis developed several classification systems measuring gradations through changing circumstances.10 When confronted with of health.18 These assess aspects like disability, functioning, and physiological stress, a healthy organism is able to mount a perceived quality of life and wellbeing. protective response, to reduce the potential for harm, and restore In primary care, the Dartmouth Cooperative Group an (adapted) equilibrium. If this physiological coping strategy (COOP)/Wonca (the world organisation of family doctors) is not successful, damage (or “allostatic load”) remains, which assessment of functional status, validated for different social may finally result in illness.11 and cultural settings, has been developed to obtain insight into the perceived health of individuals. The COOP/Wonca Mental health Functional Health Assessment Charts present six different In the mental domain Antonovsky describes the “sense of dimensions of health, each supported by cartoon-like coherence” as a factor that contributes to a successful capacity drawings.19 20 Each measures the ability to perform daily life to cope, recover from strong psychological stress, and prevent activities on a 1 to 5 scale. Reprints: http://journals.bmj.com/cgi/reprintform Subscribe: http://resources.bmj.com/bmj/subscribers/how-to-subscribe BMJ 2011;343:d4163 doi: 10.1136/bmj.d4163 Page 3 of 3 ANALYSIS BMJ: first published as 10.1136/bmj.d4163 on 26 July 2011. Downloaded from http://www.bmj.com/ on 16 July 2024 at Queen Margaret University Consortia. Protected by copyright. Such instruments offer valuable information about a variety of Provenance and peer review: Not commissioned; externally peer aspects, from functioning to the experienced quality of life. Yet reviewed. there are few instruments for measuring aspects of health like the individual’s capacity to cope and to adapt, or to measure the 1 WHO. Constitution of the World Health Organization. 2006. www.who.int/governance/eb/ who_constitution_en.pdf. strength of a person’s physiological resilience. A new 2 What is health? The ability to adapt [editorial]. Lancet 2009;373:781. formulation about health could stimulate research on this. 3 Jadad AR, O’Grady L. How should health be defined. BMJ 2008;337;a2900. 4 Smith R. The end of disease and the beginning of health. BMJ Group Blogs 2008. http:/ /blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of- Conclusion 5 health/. Larson JS. The conceptualization of health. Med Care Res Rev 1999;56;123-36. 6 Health Council of the Netherlands. Publication A10/04. www.gezondheidsraad.nl/sites/ Just as environmental scientists describe the health of the earth default/files/bijlage%20A1004_1.pdf. as the capacity of a complex system to maintain a stable 7 Kanungo S, Tsuzuki A, Deen JL, Lopez AL, Rajendran K, Manna B, et al. Use of verbal environment within a relatively narrow range,21 we propose the autopsy to determine mortality patterns in an urban slum in Kolkate, India. Bull World Health Organ 2010;88:667-74. formulation of health as the ability to adapt and to self manage. 8 Ottawa Charter for Health Promotion. www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf. This could be a starting point for a similarly fresh, 21st century 9 10 Blumer H. Symbolic interactionism: perspective and method. Prentice Hall, 1969. Schulkin J. Allostasis, homeostasis, and the costs of physiological adaptation. Cambridge way of conceptualising human health with a set of dynamic University Press, 2004. features and dimensions that can be measured. Discussion about 11 McEwen BS. Interacting mediators of allostasis and allostatic load: towards an understanding of resilience in aging. Metabolism 2003;52(suppl 2):10-6. this should continue and involve other stakeholders, including 12 Antonovsky A. Health, stress and coping. Jossey-Bass, 1979. patients and lay members of the public. 13 Antonovsky A. The sense of coherence as a determinant of health. In: Matarazzo J, ed. Behavioural health: a handbook of health enhancement and disease prevention. John Wiley, 1984:114–29. We thank Jennie Popay, Atie Schipaanboord, Eert Schoten, and Rudy 14 De Lange FP, Koers A, Kalkman JS, Bleijenberg G, Hagoort P, Van der Meer JWM, et al. Increase in prefrontal cortical volume following cognitive behavioural therapy in patients Westendorp for their thoughts. with chronic fatigue syndrome. Brain 2008;131:2172-80. Contributors and sources: This paper builds on a two day invitational 15 Lorig KR, Sobel DS, Stewart AL, Brown BW, Bandura A, Ritter P, et al. Evidence suggesting that a chronic disease self management program can improve health status conference in the Netherlands on defining health, organised by the while reducing utilization and costs: a randomized trial. Med Care 1999;37:5-14. Health Council of the Netherlands (Gezondheidsraad) and the 16 Lorig KR, Ritter PL, González VM. Hispanic chronic disease self management: a randomized community-based outcome trial. Nurs Res 2003;52:361-9. Netherlands Organisation for Health Research and Development 17 Von Faber M, Bootsma-van der Wiel A, van Exel E, Gussekloo J, Lagaay AM, van Dongen (ZonMw). At the conference a multidisciplinary group of 38 international E, et al. Successful aging in the oldest old: who can be characterized as successfully aged? Arch Intern Med 2001;161:2694-700. experts discussed the topic and were guided by a review of the literature. 18 WHO. WHO family of international classifications.www.who.int/classifications. MH organised the conference and drafted the report and this article. 19 Van Weel C, König-Zahn C, Touw-Otten FWMM, van Duijn NP, Meyboom-de Jong B. LG, HvdH, ARJ, DK, BL, KL, MIL, JvdM, PS, RS, and CvW contributed Measuring functional health status with the COOP/Wonca charts. Northern Centre for Health Care Research, University of Groningen, 1995. www.globalfamilydoctor.com/ as speakers. HS hosted the conference with JAK, who chaired it. All research/research.asp?refurl=r#R4. authors contributed to the article. JAK is guarantor. 20 Nelson E, Wasson J, Kirk J, Keller A, Clark D, Dittrich A, et al. Assessment of function in routine clinical practice: description of the COOP Chart method and preliminary findings. Competing interests: All authors have completed the ICJME unified J Chron Dis 1987;40(suppl 1):55S-63S. disclosure form at www.icmje.org/coi_disclosure.pdf (available on 21 Rockström J, Steffen W, Noone K, Persson Å, Chapin AS, Lambin EF, et al. A safe operating space for humanity. Nature 2009;461:472-5. request from the corresponding author) and declare no support from any organisation for the submitted work; no financial relationships with Accepted: 15 June 2011 any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that Cite this as: BMJ 2011;343:d4163 could appear to have influenced the submitted work. Reprints: http://journals.bmj.com/cgi/reprintform Subscribe: http://resources.bmj.com/bmj/subscribers/how-to-subscribe