Kent L Bradley, Thomas Goetz, Sheila Viswanathan, Toward a Contemporary Definition of Health, Military Medicine, Volume 183, Issue suppl_3, November-December 2018, Pages 204–207, https://doi.org/10.1093/milmed/usy213
Navbar Search Filter Mobile Enter search term Search Navbar Search Filter Enter search term SearchAristotle saw that the striving of humanity was toward being well – a physical, mental and spiritual state where life flourished. A contemporary definition of health recognizes that disease and disability can and often do co-exist with wellness. In this new conception, health is transformed from a state that requires the absence of disease to a state where the central theme is the fullness of life. Health becomes not a static state of being, but a dynamic quality of living where body, mind, and spirit are fully employed to make the most of each day.
“Healthy citizens are the greatest asset any country can have.” 1 – Winston Churchill
Too often in the USA, health is synonymous with health care. This is not merely a philosophical failure, but an economic one. In a health care-centric paradigm faced with ever-rising costs, citizens are categorized according to their disease burden and related financial demands, causing individuals to be viewed as generators of costs rather than as assets.
A health care and cost-centric paradigm also has a de facto emphasis on diseases – the source of nearly all costs – rather than on health. This makes it difficult not only to value health as an intrinsic good but also to envision a scenario where disease is tantamount to failure, both on a system and an individual level.
To make a transition from health care to health requires reframing the belief that individuals belong on the negative side of a balance sheet. When viewed as an expense, all actions are oriented around reducing costs. This tendency is, of course, understandable; it is easier to focus on what we see – expenses – rather than what is unseen – human potential. The tendency to focus on what is seen explains why we think about health in terms of disease versus potential, emphasizing sick care over wellness and prevention. Harry Truman shared this sentiment 60 years ago, when he looked to improve the health status of the nation. “We should resolve now that the health of this nation is a national concern,” Truman said, “that financial barriers in the way of attaining health shall be removed; that the health of all its citizens deserves the help of all the nation.” 2 It may be decades later, but now is the time to adopt Truman’s argument and reorient our health care system toward health. When viewed as an asset, rather than a cost, individuals are incentivized to maximize their full potential.
First, we should define what is meant by health. The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” 3 This definition expands health into well-being, but it lacks clarity. The “not merely” suggests the prerequisite of health as the absence of disease or infirmary. In other words, the absence of disease is necessary, but not sufficient – it is still part of the equation.
A contemporary definition of health could reach beyond this paradigm to recognize that we are all, to some extent, less than perfect, that we each have aspects that need care, and that we all are in some way infirm or even “diseased.” It is not the absence of disease that sets the stage for health but the fullness of life. To borrow a phrase from the literature of mindfulness, health is about being present in the moment. The question of health becomes an observational one, focused on the individual: In this moment, do you feel like you are fully alive? Are you in your optimal state of being based on your current conditions? Health becomes contextual and functional. By this definition, an individual with a chronic disease may still be healthy. And by this definition, we can experience health until the day we die. Indeed, we can even experience health as we die.
“When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied.” 4 – Herophilus
The Greeks understood living well as eudaimonia, which translates to well-being or happiness. At its core is a notion of flourishing, in mind, body, and spirit. This is not purely a philosophical abstraction. It also has relevance when applied to the strength of a nation, or a nation’s fighting force. Former Chairman of the Joint Chiefs of Staff, Admiral Michael Mullin, observed that “regardless of one’s beliefs in a mind–body duality, a growing body of scientific evidence, as I read it, certainly links the general health of the body with the state of one’s perceptions of well-being. Scientists have also gathered ample evidence that one’s attitudes toward wellness influence how one maintains one’s physical health.” 5 Hippocrates picks up on this theme when he refers to regimens in the Hippocratic Oath. The original Greek term is diatia. The regimen, when taken from its original context, is speaking about the food or diet but in its secondary meaning means a way of living or mode of life or “rules of life” that is the way one lives one’s life. 6
Moreover, the notion of individual health is intertwined with our national ideals of society, justice, and ethical decision-making. Healthy citizens make for a healthy society. This association suggests a tangible link between social factors and determinants of individual health. Factors such as financial well-being, geographic location, family dynamics, safety, access to healthy food, to name just a few create buffers or magnifiers that support or hinder our ability to reach our potential. Our health is not a unique attribute that is determined in isolation by our genetic make-up. Our health is shaped largely by a host of environmental and societal factors that allow for a unique expression of our genetic make-up.
In many ways, this is an old idea. Ancient philosophers argued that community was inextricably related to the creation of health. Even before germ theory proved it, the number one threat to humankind throughout history has been infectious diseases. One’s state of mind or emotional health, albeit helpful, did little to thwart deadly microbes such as cholera, yellow fever, and tuberculosis. Today in the USA, these diseases are largely absent from mainstream consciousness; instead, chronic diseases have become both the leading cause of death and the main preoccupation of medicine.
Today, it is possible for individuals to live for decades, years, or even the majority of their lives with a chronic illness. In turn, the increasing tendency to define pre-conditions as disease states, from pre-diabetes to metabolic syndrome to hypercholesterolemia, implies that more people fall under the classification of diseased. This phenomenon, where disease is the new normal, has saved and improved thousands of lives through an emphasis on prevention and early detection. But it likewise means that the traditional disease-centric orientation of health is woefully out of date. It demands that society acknowledge the inadequacy of previous conceptions of disease and health, and respond.
But how? By comparison, the response to infectious disease was fairly obvious. The germ theory gave humanity a better understanding of the etiology of infection, and the power to physically pinpoint a cause that had previously been invisible. The response, then, was linear: Clean up our communities with investment and policies that supported basic hygiene. These steps, mounted decades before the advent of antibiotics, helped push infectious disease to the margins and created the conditions for modern health.
The best response to counteract the growth of chronic illnesses is not so self-evident. With chronic diseases now the norm, what is the necessary collective societal response? What does it demand us to do? Perhaps the answer lies in the lessons provided through several vignettes.
“Example is not the main thing in influencing others. It is the only thing.” – Albert Schweitzer
First, let us meet Mark, a high school counselor who effuses health from his wheelchair. Diagnosed with multiple sclerosis nearly 20 years ago, he determined that this chronic condition was not going to hold him back. He is consistently in the classroom teaching and in his counseling office supporting his students. Yes, he has several significant physical limitations that his progressively disabling disease created. But he has maintained a positive outlook on life and constantly is learning and growing.
This willingness to be open to new experiences, learn, and reflect created what we would call wisdom. Mark’s wisdom, in turn, helped students frame their life issues. Here is a person who clearly is optimally healthy – he had a physical condition that limited his activity but he remained highly productive and would view himself overall as healthy. This individual’s situation is repeated by millions of people who live with a chronic condition. One lesson is that health is not binary – either you have it or you do not – and neither are its core domains of body, mind, and spirit. You can be healthy despite significant assault on one particular domain – body, mind, or spirit.
Now let us take the case of Johnny. He was diagnosed with schizoaffective disorder and became a threat to himself and others. He often had delusions and uncontrolled violent outbursts. His body was built like Atlas. If you were to ask Johnny if he was healthy he would say sure he was – he could bench press 300 lbs and felt fine. However, Johnny was not at all healthy. He was barely able to function in society. His case suggests that the condition of health may be more heavily weighted toward the mind and spirit. Descartes authored the phrase, “I think therefore I am.” The mind is a creative force that is energized by the spirit. To some extent, the body appears to be more of a sideline contributor.
Now, let us meet Susan – an alcoholic who has been sober for 10 years. Susan is not easy to pinpoint on the traditional spectrum of health and disease. Would you consider her healthy? More important, would she consider herself healthy? Does she have a disease? It is tempting to say yes, but consider her physical condition: her liver functions normally. She is functioning well in her job and is genuinely happy. She volunteers her time, like many alcoholics who manage to stay sober, helping others in a support group. By all accounts, to include her own, she is healthy but she knows that when her spirits are low she is vulnerable to the call of old thoughts that could lead to alcohol.
These vignettes highlight individuals who are living with chronic conditions. Are they healthy and if so, why? Peeled to its essence, health is not a condition or state but the very substrate of life. To have health is to have life. To be full of health is to be full of life. The substrate has a physical element but it also has a mental and emotional component. As with soil, the elements of physical (body), mental (mind), and emotional (spirit) can be optimally balanced to create a fertile ground for life. Each element becomes necessary but not sufficient. It is not necessarily the equal parts but the blend that is optimal for each individual to grow and thrive.
In this new definition, health is the combined elements of the body, mind, and spirit working in harmony to create the basis for the fullness of life. “Healthy” is a description of a flourishing life. How to develop this flourishing life moves us beyond the physical and beyond our genetic endowment. A flourishing life is determined by those actions and forces that impact our body, mind, and spirit.
It is helpful, here, to consider the determinants of health: those inputs that coalesce into the output of our relative state of health. Previous research has found that, in proportion to their contribution to premature death, the major determinant of human health is behavior. Even more profoundly, when behavior is combined with the influences of social circumstances and environmental exposure, these account for over 50% of one’s health. The opportunity here is profound, because these influences – behavioral, social, and environmental – are eminently modifiable, but have yet to be well addressed by conventional approaches to medicine and health (Fig. 1). 7
Influence of health determinants.
