Appunti Igiene

What is health?

Fiona Godlee editor, BMJ

In a BMJ editorial in December 2008 Alex Jadad and Laura O’Grady called for a “global conversation” about how we define health (BMJ 2008;337:a2900). This week Jadad and colleagues present the results of that conversation, initiated via a blog on bmj.com to which a good number of you responded (http://bit. ly/cfU5yh), and concluded at a two day meeting in the Netherlands in December 2009 (doi:10.1136/bmj.d4163). They propose a new definition of health as “the ability to adapt and self manage” in the face of social, physical, and emotional challenges.

Why should we be interested in defining health? Because if health is the goal of healthcare and research, we need to know what it looks like and how to measure it. As these articles explain, the currently accepted definition, formulated by WHO in 1948, is no longer helpful and is even counterproductive. Its emphasis on “complete physical, mental and social wellbeing” was radical in its day for stepping away from defining health as the absence of disease. But it is absolute and therefore unachievable for most people in the world. As Richard Smith, one of the authors of this week’s article, pointed out in a BMJ blog, it “would leave most of us unhealthy most of the time” (http://bit.ly/fnpzex). Indeed, the article says that the WHO definition has contributed unintentionally to the medicalisation of society, as more and more human characteristics are recruited as risk factors for disease.

The WHO definition is also unworkable for other reasons, the authors say. In the face of an ageing global population with an increasing burden of chronic disease, it “minimises the role of the human capacity to cope autonomously with life’s ever changing physical, emotional, and social challenges and to function with fulfilment and a feeling of wellbeing with a chronic disease or disability.”

Jennifer Bute provides a moving example of this human capacity. While still practising as a general practitioner she developed the first symptoms of dementia as well as cardiac problems (doi:10.1136/bmj.d4278). Without minimising the challenge of what she has had to endure, her cardiologist comments that coping and adapting were probably easier for her than for others less resourceful and capable. If health is our goal, and if the new definition meets our current realities, the next question is: how can we build and sustain the human capacity to adapt and cope?

Edwin Heathcote is the architecture correspondent for the Financial Times. He describes one approach to maximising human health—the development of “age friendly” cities (doi:10. 1136/bmj.d4418). This initiative aims to reverse the trend of removing or excluding older people from active life in cities. How can these people be brought back so that not only they but also the city survive and flourish? The answer, it turns out, is not the current vogue for ramps, big bold signs, benches, and lots of green space.

This week’s articles are the start of six weeks’ coverage building up to the UN summit on non-communicable diseases in September. Other articles will focus on how we should be tackling the key shared risk factors behind the global epidemic of chronic disease—poor diet, alcohol, tobacco, and physical inactivity. As always, we hope for your input via rapid responses on bmj.com.

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. ² proposes changing the emphasis towards the ability to adapt and self manage in the face of social, physical, and emotional challenges

The current WHO definition of health, formulated in 1948, describes health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”⁴ At that time this formulation was groundbreaking because of its breadth and ambition. It overcame the negative definition of health as absence of disease and included the physical, mental, and social domains. Although the definition has been criticised over the past 60 years, it has never been adapted. Criticism is now intensifying,⁵ and as populations age and the pattern of illnesses changes the definition may even be counterproductive. The paper summarises the limitations of the WHO definition and describes the proposals for making it more useful that were developed at a conference of international health experts held in the Netherlands.⁶

Limitations of WHO definition

Most criticism of the WHO definition concerns the absoluteness of the word “complete” in relation to wellbeing. The first problem is that it unintentionally contributes to the medicalisation of society. The requirement for complete health “would leave most of us unhealthy most of the time.”⁴ It therefore supports the tendencies of the medical technology and drug industries, in association with professional organisations, to redefine diseases, expanding the scope of the healthcare system. New screening technologies detect abnormalities at levels that might never cause illness and pharmaceutical companies produce drugs for “conditions” not previously defined as health problems. Thresholds for intervention tend to be lowered—for example, with blood pressure, lipids, and sugar. The persistent emphasis on complete physical wellbeing could lead to large groups of people becoming eligible for screening or for expensive interventions even when only one person might benefit, and it might result in higher levels of medical dependency and risk.

The second problem is that since 1948 the demography of populations and the nature of disease have changed considerably. In 1948 acute diseases presented the main burden of illness and chronic diseases led to early death. In that context WHO articulated a helpful ambition. Disease patterns have changed, with public health measures such as improved nutrition, hygiene, and sanitation and more powerful healthcare interventions. The number of people living with chronic diseases for decades is increasing worldwide; even in the slums of India the mortality pattern is increasingly burdened by chronic diseases.⁷

Ageing with chronic illnesses has become the norm, and chronic diseases account for most of the expenditures of the healthcare system, putting pressure on its sustainability. In this context the

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2. Stile di vita e comportamenti individuali
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• Secondo la Conferenza ONU di Alma Ata da parte delle Nazioni nel 1975 la vita globale della salute si propone il fine di ottenere