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Towards a medicine based on the concept of health
PREVENTIVE
2,3&l-312
MEDICINE
(1973)
EDITORIAL Towards
An Astounding
a Medicine
Based
on the Concept
of Health
Contradiction
Present health systems are based on the concept of disease. In its original and present widest acceptance the word health is the antonym of the word disease. There is some degree of logical inconsistency in using the terms “health systems” when the actual concern is disease and not health. There must be, of course, an explanation for the historical process that has led to such a contradiction in our language. More important than an inquiry on this historical process is the fact that this ambiguous use of the language has conditioned an attitude that totally disregards the concept of health in medical research, government programs, legislative mandate, and insurance policy. The concept of health has never been defined in terms of its attributes. Is it because health is an indefinable axiom? It is doubtful that such an hypothesis has ever been formulated. The truth is that the attributes of health have not been investigated in any systematic manner. In the medical school, disease, or illness, is defined as a departure from health, but the meaning of health is considered implicit in the word and is not defined. The physician has not been educated and is not thinking in terms of health. Those who, in one way or another, are involved in the planning, development, administration, coordination, and evaluation of “health services” are similarly conditioned by this negative approach to the concept of health.
Need for a Definition
of Health
But why do we need a definition of health? A definition of health must be sought because, among other reasons: (a) Surveys of population health status indicate that the progress made in the last century and a half is much less the result of an eradiction of disease than of the environment’s control by the sanitation of waters and sewage, the prevention of spread of disease by isolating health offenders, and the promotion of health by such measures as the stimulation of immunological resistance. (b) The search and identification of the attributes of health are needed, if nothing else, to make progress in our knowledge of man and of his future. The indiscriminate use of the terms health and disease not only has led to unbalanced emphasis on the concept of disease, which has marked social and political attitudes toward the problems presented by health and disease, but it is also a major dialectic hurdle in the study and discussion of those problems. A strong, deep feeling tells us that the concept of health must be fundamental in the understanding of human behavior and of the irrational forces that make the species fight for its survival, and in man’s generational, renewed aspirations for a better world. (c) Scientific 309 Copyright @ 1973 by Academic Press, Inc. All rights of reproduction in any form reserved.
310
EDITORIAL
and technological achievements modify constantly the way we see things. Thus, recent advances in science and technology make possible more than ever the integrative description of complex entities, and health, probably, can be defined in terms of some of the basic concepts of systems theory. Outside the disease model of classical medicine, which is very much limited to accute disease, little progress has been made in the understanding of diseases which establish themselves silently, sluggishly, progressively, and, to a great extent, irreversibly. A positive definition of health appears to be fundamental in perceiving the dawn of degenerative disease and in providing broad concepts for preventive medicine and health promotion. (d) In approaching the problems of health and disease, the economical aspect is one that requires major consideration. This is certainly reflected in the attention presently given to benefitcost analysis in the national planning of health programs for the next five to ten years. But, once more, the concept of health is not considered in this planning, Is it not appropriate to ask the question, are there any areas where the cost of preventing disease or promoting health would compare favorably to the cost,of treating disease? The development of a concept of health that can be incorporated in economic considerations is also obviously needed.
Approaches to Definition
of Health
A definition of health at the conceptual level may be helpful but of doubtful use. An effort must bemade to generate an operational definition based on quantitatable variables and functional relationships. Theoretically, one may conceive the concept of.absolute health. Such a concept would imply the resistance to any kind of disease. The problem with this concept of total or absolute health is that it is still anchored on the concept of disease and that it has not been shown to be an empirical reality. For practical purposes, the concept of health is limited to the resistance to a certain disease prevailing in a certain environment at a certain time. Although this concept of relative health is more realistic and manageable than the previous concept, its unique foundation is still the lack of disease. But, following this line.of discourse and given that, for the moment, we can think only in relative terms, the question is: Are there any measures of health? The attributes of health should be expressed in terms of physiological and psycho-social variables and by definable relationships,between the individual and his environment, both physical and nonphysical. A distinction that should be made from the outset is the difference between individual and social health. If there are definable attributes of health, then, these attributes should be found in all subjects who exhibit good health. Thus, social health should be rated poor if the number of subjects exhibiting those attributes in a population were small, Obviously, if health can be defined by measurable attributes, it should first be measured in the individual and after this, in the population. To do it the other way around leads to .the observation of correlations which most of the time have no interpretation from a causal point of view. Because the assessment of “social health” is more easily amenable to more or less well established statistical techniques, a number of indices of health have been proposed (Chiang,
EDITORIAL
311
and Krall) which are of limited pract.ical use, particularly in that which concerns each single person. Our approach to the definition of health contemplates the study of man’s performance under a variety of circumstances. These circumstances have to do with man’s capability to fulfill certain functions, with the optirnality of such performance in relation to a set of goals, and with his adaptability to unexpected personal and environmental changes. Thus, under the capability concept, every man can be described in terms of a profile of his abilities, a measurement of his maximal capacity for physical work, a determination of the reserve of his physiological functions and an assessment of his psychosocial behavior. Under the optimality concept man can be described in terms of the efficiency of his physical and psycho-social performance; this in turn entails descriptions of modalities of functional regulation and of the development of functional hierarchies and comparative studies on the performance of adaptive mechanisms in response to normal and abnormal changes in the environment. Finally, under the adaptability concept, man can be described in terms of his potential for learning new things, for overcoming physical disability, and for adjusting to changes in the universe in which he lives. This, we believe, would be a more positive attempt to uncover the attributes of health and to develop a better comprehension of how to preserve it, how to detect early deviations from it, how to restore it when impaired, and how to promote it by rational means. Obviously, this approach will require the identification and recording of variables which relate to physiological function; state of nutrition, body structure, and composition; physical and psychic stress; individual and social behavior; cultural habitat; and genetic background. Objective for a Plan of Action Present private and government programs in the field of health are based upon the concept of disease. This is a barrier to the identification of positive attributes of health and to the availability of financial support for research targeted towards health rather than towards disease. An appeal is made to the imagination and initiative of private concerns and government agencies to effectively participate in producing a change in favor of this different view of health in our society. The creation of an institute or institutes totally dedicated to the study of health is advocated. The activities of such institute or institutes should produce scientific evidence to prove or disprove the hypothesis that the lack of a positive definition of health hampers progress in our understanding of the conditions which create well-being, preserve health, prolong life, and of those which are responsible for the surreptitious inroads of degenerative disease. REFERENCES 1. CHIANG, C. L. An index of health: Mathematical models. Vital and Health Statistics 5 (1965), 1-19. 2. CHIANG, C. L. AND COHEN, R. D. How to measure health: A stochastic model for an index of health, Internat. J. Epidemiology 2 (1973), 7-13.
312 3. KFNLL, J. M. An index of health: Fellowship No. 5-FOl-CM32657.
EDITORIAL An application
in accidents,
unpublished
data, Research
DAVID
Baylor
CARDUS
College of Medicine Houston, Texas 77025
2,3&l-312
MEDICINE
(1973)
EDITORIAL Towards
An Astounding
a Medicine
Based
on the Concept
of Health
Contradiction
Present health systems are based on the concept of disease. In its original and present widest acceptance the word health is the antonym of the word disease. There is some degree of logical inconsistency in using the terms “health systems” when the actual concern is disease and not health. There must be, of course, an explanation for the historical process that has led to such a contradiction in our language. More important than an inquiry on this historical process is the fact that this ambiguous use of the language has conditioned an attitude that totally disregards the concept of health in medical research, government programs, legislative mandate, and insurance policy. The concept of health has never been defined in terms of its attributes. Is it because health is an indefinable axiom? It is doubtful that such an hypothesis has ever been formulated. The truth is that the attributes of health have not been investigated in any systematic manner. In the medical school, disease, or illness, is defined as a departure from health, but the meaning of health is considered implicit in the word and is not defined. The physician has not been educated and is not thinking in terms of health. Those who, in one way or another, are involved in the planning, development, administration, coordination, and evaluation of “health services” are similarly conditioned by this negative approach to the concept of health.
Need for a Definition
of Health
But why do we need a definition of health? A definition of health must be sought because, among other reasons: (a) Surveys of population health status indicate that the progress made in the last century and a half is much less the result of an eradiction of disease than of the environment’s control by the sanitation of waters and sewage, the prevention of spread of disease by isolating health offenders, and the promotion of health by such measures as the stimulation of immunological resistance. (b) The search and identification of the attributes of health are needed, if nothing else, to make progress in our knowledge of man and of his future. The indiscriminate use of the terms health and disease not only has led to unbalanced emphasis on the concept of disease, which has marked social and political attitudes toward the problems presented by health and disease, but it is also a major dialectic hurdle in the study and discussion of those problems. A strong, deep feeling tells us that the concept of health must be fundamental in the understanding of human behavior and of the irrational forces that make the species fight for its survival, and in man’s generational, renewed aspirations for a better world. (c) Scientific 309 Copyright @ 1973 by Academic Press, Inc. All rights of reproduction in any form reserved.
310
EDITORIAL
and technological achievements modify constantly the way we see things. Thus, recent advances in science and technology make possible more than ever the integrative description of complex entities, and health, probably, can be defined in terms of some of the basic concepts of systems theory. Outside the disease model of classical medicine, which is very much limited to accute disease, little progress has been made in the understanding of diseases which establish themselves silently, sluggishly, progressively, and, to a great extent, irreversibly. A positive definition of health appears to be fundamental in perceiving the dawn of degenerative disease and in providing broad concepts for preventive medicine and health promotion. (d) In approaching the problems of health and disease, the economical aspect is one that requires major consideration. This is certainly reflected in the attention presently given to benefitcost analysis in the national planning of health programs for the next five to ten years. But, once more, the concept of health is not considered in this planning, Is it not appropriate to ask the question, are there any areas where the cost of preventing disease or promoting health would compare favorably to the cost,of treating disease? The development of a concept of health that can be incorporated in economic considerations is also obviously needed.
Approaches to Definition
of Health
A definition of health at the conceptual level may be helpful but of doubtful use. An effort must bemade to generate an operational definition based on quantitatable variables and functional relationships. Theoretically, one may conceive the concept of.absolute health. Such a concept would imply the resistance to any kind of disease. The problem with this concept of total or absolute health is that it is still anchored on the concept of disease and that it has not been shown to be an empirical reality. For practical purposes, the concept of health is limited to the resistance to a certain disease prevailing in a certain environment at a certain time. Although this concept of relative health is more realistic and manageable than the previous concept, its unique foundation is still the lack of disease. But, following this line.of discourse and given that, for the moment, we can think only in relative terms, the question is: Are there any measures of health? The attributes of health should be expressed in terms of physiological and psycho-social variables and by definable relationships,between the individual and his environment, both physical and nonphysical. A distinction that should be made from the outset is the difference between individual and social health. If there are definable attributes of health, then, these attributes should be found in all subjects who exhibit good health. Thus, social health should be rated poor if the number of subjects exhibiting those attributes in a population were small, Obviously, if health can be defined by measurable attributes, it should first be measured in the individual and after this, in the population. To do it the other way around leads to .the observation of correlations which most of the time have no interpretation from a causal point of view. Because the assessment of “social health” is more easily amenable to more or less well established statistical techniques, a number of indices of health have been proposed (Chiang,
EDITORIAL
311
and Krall) which are of limited pract.ical use, particularly in that which concerns each single person. Our approach to the definition of health contemplates the study of man’s performance under a variety of circumstances. These circumstances have to do with man’s capability to fulfill certain functions, with the optirnality of such performance in relation to a set of goals, and with his adaptability to unexpected personal and environmental changes. Thus, under the capability concept, every man can be described in terms of a profile of his abilities, a measurement of his maximal capacity for physical work, a determination of the reserve of his physiological functions and an assessment of his psychosocial behavior. Under the optimality concept man can be described in terms of the efficiency of his physical and psycho-social performance; this in turn entails descriptions of modalities of functional regulation and of the development of functional hierarchies and comparative studies on the performance of adaptive mechanisms in response to normal and abnormal changes in the environment. Finally, under the adaptability concept, man can be described in terms of his potential for learning new things, for overcoming physical disability, and for adjusting to changes in the universe in which he lives. This, we believe, would be a more positive attempt to uncover the attributes of health and to develop a better comprehension of how to preserve it, how to detect early deviations from it, how to restore it when impaired, and how to promote it by rational means. Obviously, this approach will require the identification and recording of variables which relate to physiological function; state of nutrition, body structure, and composition; physical and psychic stress; individual and social behavior; cultural habitat; and genetic background. Objective for a Plan of Action Present private and government programs in the field of health are based upon the concept of disease. This is a barrier to the identification of positive attributes of health and to the availability of financial support for research targeted towards health rather than towards disease. An appeal is made to the imagination and initiative of private concerns and government agencies to effectively participate in producing a change in favor of this different view of health in our society. The creation of an institute or institutes totally dedicated to the study of health is advocated. The activities of such institute or institutes should produce scientific evidence to prove or disprove the hypothesis that the lack of a positive definition of health hampers progress in our understanding of the conditions which create well-being, preserve health, prolong life, and of those which are responsible for the surreptitious inroads of degenerative disease. REFERENCES 1. CHIANG, C. L. An index of health: Mathematical models. Vital and Health Statistics 5 (1965), 1-19. 2. CHIANG, C. L. AND COHEN, R. D. How to measure health: A stochastic model for an index of health, Internat. J. Epidemiology 2 (1973), 7-13.
312 3. KFNLL, J. M. An index of health: Fellowship No. 5-FOl-CM32657.
EDITORIAL An application
in accidents,
unpublished
data, Research
DAVID
Baylor
CARDUS
College of Medicine Houston, Texas 77025