What Is “Health”?

By Gerrit Van Wyk.

“Health” is complex.

We talk a lot about “health” without knowing or agreeing on what it is. There is “health” care, restoring “health”, “health” providers, and so on, but what is “health”? It matters a lot because how we define “health” determines related actions we take, and how.

The World “Health” Organization used to say “health” is a state of complete physical, mental, and social well-being, and not merely the absence of disease. One can see how it is influenced by the clockwork model of reality; it is a state of perfection, a thing, or a want, which means it can be measured, and if we deviate should seek to restore this state. More recently it was changed to: the extent an individual or group can realize aspirations and satisfy needs to cope with the environment, which is still a clockwork orientation. Accordingly, politically “health” is a fundamental right, and States must protect and promote that, but what precisely is this “health” that must be protected?

What are the facts about “health”? Research shows 750 of every 1,000 adults in society experience symptoms of not being well, such as headaches, backache, sprains, colds, etc., during a month, about 250 will be concerned enough to seek help from health professionals, and about 5% will require acute care in hospitals, etc. What that means, in common with complex phenomena, is one end up with a normal distribution as follows.

Five percent of people show the perfection sought in the early WHO definition, but with no guarantee for maintaining it (A), and another 20% show no symptoms but smoke, overeat, participate in sport that may injure them, etc., (B). This is the 25% in the study remaining symptom-free. About 50% of people have symptoms but can self-manage it (C), and when we speak about “health” care, we talk about the 25% on the right, which, in extreme cases, require specialized care (E). What this means is all of us constantly move back and forth on this sliding scale, finding ourselves in different spaces at different times. Based on the facts, “health” now makes sense, and looks completely different, which has immense implications for how health “care” is planned and practiced.

The purpose of acute care (E) is not to “cure” people, but getting them well enough to transfer care to the community and the care of family practitioners (D), the purpose of community care is providing patients with the knowledge and skills to care for themselves when appropriate (C), and the purpose of patients is managing themselves in such a way that they remain symptom free (B), and not to strive for Barbie and Ken perfection (A), as the WHO used to suggest. In other words, the purpose of health care is shifting people to the left on the health scale, and the onus is on them to take care of themselves in such a way they won’t slide to the right, or manage as best they can, given available resources.

The model also shows where current health “care” practice falls short. It is well known that simple low-cost measures such as better food, sanitation, vaccination, better housing, etc., (which makes perfect sense in terms of health as a distribution), has a significantly bigger influence on “health” than acute care, and yet, the emphasis remains on the latter. The conversation in Canada is about the Federal Government providing more funds to the provinces to prop up the 25% on the right, and that we need more physicians, nurses, and other health care providers to do more to the 25%, and next to none about using it to improve the 50% in the middle, reducing the load on the right, which makes more sense.

It also shows the elephant in the room, namely patient expectations, which in North America today is skewed to the right of the curve by the media, politicians, and the physician community. Like all things complex, a concept of “health” emerges from social relationships and interactions, which means it differs between nations, cultures, and subcultures, and is constantly changed by their actions.

Humans evolved to put things in categories and classifications, and modern society delegated the authority to do so for health care and police it to the health profession. From the interaction between health care and society at large, a concept of illness emerges determining who is sick and who not, who should be treated and how, etc., which feeds back into a society’s concept of “health”. A concept of illness also impacts on how that society sees suffering and death.

The current model for determining what is normal is the clockwork perspective. It tells who may do what jobs, who does military service, go to mental institutions, etc. The way we classify determines how a society functions and adapts to conform to the classifications, and the institutions created for those classified as not normal who, in terms of clockwork reality, must be changed to fit the norm and be normal.

In our society suffering, pain, and death from injury, disease or by suicide is abnormal, and must be prevented, and if it can’t, new technologies must be invented adding to the cost of health care. Most such treatments don’t make people “healthy” and may itself cause harm, and mistakes in diagnosis and treatment can also make healthy people sick. Treatment decisions are influenced by the industries creating technology for profit, and a perspective that high-technology care in hospitals is good and will cure all problems.

People express their health wants to legal and political institutions, who create regulations and bureaucracies to enforce them, and physicians and other health care providers belong to professional societies, whose cultures and norms influence standards and physician behavior. Finally, health care has a say in our social environment or biosphere, including housing, work, water, sewerage, etc., and this influence on behavior and our environment can also cause illness or health.

If you connect all these relationships and interactions on a system dynamics model to show how they interact, it looks as follows.

Most people feel overwhelmed and switch off when they look at the diagram, which means they miss the point. What we call “health” is a complex perspective emerging from many social interrelationships and interactions, and knowing that matters.

To sum up: the current clockwork perspectives of “health” on which policy decisions and planning is based, do not reflect reality and does not work. It will be more fruitful to pay attention to the reality of what happens on the ground and how we understand “health” socially, but, more importantly, to have a dialogue about it as part of a conversation transforming an archaic system no longer serving the needs of people today. Our understanding of “health” emerges from the societies we belong to, and profoundly influences the institutions we create to do deal with it. We can’t ignore that.