UNDERSTAND WHAT IS HEALTH?
Health is not a “state of complete physical, mental, and
social well-being”. And nor is it “merely the absence of disease or
infirmity”. The first part of this formulation is enshrined in WHO's
famous founding constitution, adopted in 1946. It was supposed to
provide a transformative vision of “health for all”, one that went
beyond the prevailing negative conception of health based on an
“absence” of pathology. But neither definition will do in an era marked
by new understandings of disease at molecular, individual, and societal
levels. Given that we now know the important influence of the genome in
disease, even the most optimistic health advocate surely has to accept
the impossibility of risk-free wellbeing.
That said, the
conjunction of the physical, psychological, and social remains
powerfully relevant to this day. Indeed, this framework should be
extended in two further dimensions. First, human health cannot be
separated from the health of our total planetary biodiversity. Human
beings do not exist in a biological vacuum. We live in an interdependent
existence with the totality of the living world. The second dimension
is in the realm of the inanimate. The living world depends upon a
healthy interaction with the inanimate world. Thanks to the science of
climate change, we now understand only too well how contingent our human
wellbeing is on the “health” of the Earth's systems of energy exchange.
Science
has contributed to our understanding of wellbeing through an ingenious
apparatus of techniques that reveal not only the causal pathways of ill
health but also evidence for their amelioration. But the language of
science can be inhibitory. For example, the notion of suffering is no
longer fashionable. It is not a scientific word; it seems vague and
old-fashioned, harking back to a time of clinical impotence, when
patients had to endure and tolerate pain without respite or relief.
Science aims to deliver the means to eliminate much of what once passed
for human suffering.
But as the opening article in our
Series on health in the occupied Palestinian territory shows, dimensions
of suffering, especially at the community level, are measurable and
often severe. Science has not eradicated suffering, despite its enormous
power to deliver technologies to improve health. Being more humble
about the experience of individuals, rather than simply drawing up
reductive report cards of their health status, opens up the possibility
for a more realistic understanding of what it means to be healthy. The
fact is that one cannot be healthy in an unhealthy society.
Health
certainly has to encompass these complex determinants of illness. But
to say this can induce a feeling of fatigue, even defeat. The obstacles
to a minimum quantity of health seem so huge and so complex that it is
almost impossible for a single doctor to have any influence on their
effects. But if we take a more modest view of what health means, perhaps
we may be able to transcend the complexities of disease and offer a
very practical mission for modern medicine.
That mission was set out most clearly by a French physician, Georges Canguilhem, in his 1943 book, The Normal and the Pathological.
Canguilhem rejected the idea that there were normal or abnormal states
of health. He saw health not as something defined statistically or
mechanistically. Rather, he saw health as the ability to adapt to one's
environment. Health is not a fixed entity. It varies for every
individual, depending on their circumstances. Health is defined not by
the doctor, but by the person, according to his or her functional needs.
The role of the doctor is to help the individual adapt to their unique
prevailing conditions. This should be the meaning of “personalised
medicine”.
The beauty of Canguilhem's definition of
health—of normality—is that it includes the animate and inanimate
environment, as well as the physical, mental, and social dimensions of
human life. It puts the individual patient, not the doctor, in a
position of self-determining authority to define his or her health
needs. The doctor becomes a partner in delivering those needs.
For
a scientific journal too, Canguilhem's definition is liberating. By
using adaptability as the test of health, a journal can evolve to
address the changing circumstances of disease. Adaptability frees us to
be agile in the face of shifting forces that shape the wellbeing of
individuals and populations. Canguilhem's definition also allows us to
respond to disease globally, taking account of the context of conditions
in a particular place, as well as time.
Health is an
elusive as well as a motivating idea. By replacing perfection with
adaptation, we get closer to a more compassionate, comforting, and
creative programme for medicine—one to which we can all contribute.
