(Reprinted by the Kind Permission of Steven Jonas
and the Springer Publishing Company)
Talking About Health and Wellness With Patients:
Integrating Health Promotion and Disease Prevention
into Your Practice
by Steven Jonas
Chapter 2 - What are Health and Wellness?
I. DEFINITIONS OF HEALTH
A. Different Uses of the Term
"Health," as well as "disease," "illness," and "wellness" are terms we often use without considering their precise definitions. There are many (Arnold and Breen; Downie, et al, Chap. 2). It is easy to think of health simply as being the absence of disease, as well as to think of illness and disease as being interchangeable terms. In fact, health and disease are not simply opposites, and disease and illness do not mean the same thing (Downie, et al, Chap. 2; Kass; Wolinsky, Chap. 4).
Complicating matters further, in many of our uses of the word "health," we are not actually referring to any true aspect of health in virtually any sense of the term. The word "health" is often used as an adjective when by no definition is health the focus of that use. For example, what we often call "health statistics" are in fact disease statistics, and "health care," certainly in the Western approach, is in fact most often disease care. Jago (1975) listed 43 examples of such use, including the terms "health status," "health center," and "health worker." In practice, these most often mean, respectively, "sickness status," "disease treatment center," and "disease care worker."
B. The Greek View
The consideration of just what health is has a long history and a wide geographical distribution. The ancient Greeks made a philosophical distinction between the concepts of health and disease. As the eminent medical historian Henry Sigerist said (1941, p. 57): "The [Greek] physicians had an explanation for health. Health, they believed, was a condition of perfect equilibrium. When the forces or humors or whatever constituted the human body were perfectly balanced, man was healthy. Disturbed balance resulted in disease. This is still the best general explanation we have." And it is the source of Concept VII.
This was the view of the followers of the Greek goddess of health, Hygeia, daughter of Apollo the supreme healer (Durant, pp.342-348). The Greek physician Hippocrates, for whom the present professional oath that many medical school graduates take is named, focussed much of his own teaching on health promotion. For the individual, he addressed such elements as exercise, nutrition, and the active application of the "Greek mean," that is, moderation in all things, to achieve the desired balance in life. For the population as a whole, Hippocrates' teaching addressed public health measures, to the extent they were understood at the time.
In contrast with the "hygienists," followers of the Greek god of medicine, Asklepios (a son of Apollo), concentrated on disease and miracle cures. It is interesting to note that while both Hygeia and Asklepios were children of Apollo, it was the female who focussed on health while the male focussed on disease. Thinking, for example, of the principal philosophical foci of male-dominated Western medicine as contrasted with those of female-dominated nursing, how marvelously modern that distinction is!
The Romans continued the Greek "Hygienic" approach to health, stressing its public health aspects especially. However, with the collapse of civilization that accompanied the gradual disintegration of the Roman Empire and the eventual rise of Christianity, in Europe the interest in disease almost entirely displaced any interest in the Greek idea of health. The concept of health, for example, as a state of optimal balance, would have little meaning either to the disease-wracked populace living in Europe from the Dark Ages through the Enlightenment, or to the practitioners of one kind of another who attempted to take care of them. Magic and religious salvation, on the one hand, and on the other, miracle cures (and later) the early stages of scientifically-based treatment of any departure from health after it became apparent, became the focus of what attention to health there was. As is well-known, in contemporary Western medicine treating departures from health after they occur, the Asklepian (Aesculapian in Latin) approach, still receives most of the attention, in contrast with the Greco-Roman hygienic approach.
C. The Modern Western Approach
In our own era, even after the vast development of science-based medicine, the idea of an approach to health based on curing, even of miracle cures (think of the term "medical miracle" often applied to the latest surgical or pharmaceutical intervention appearing on the scene) has persisted. It is still a seductive dream. Cures are sought that can compensate, not for unknown or misunderstood causes of illness, not just for causes of illness and injury beyond anyone's control, but also for well-known abuses of the body the individual and society have themselves perpetrated.
The latter group of cures is designed to correct at a stroke, in full or in part, the effects of cigarette smoking, or of eating an unhealthy diet, or of working in an unhealthy workplace, over a period of years. This is the case even when prevention would be much more effective in promoting health than treatment would be, to say nothing of being much cheaper. For many Western health professionals it seems to be easier to care for disease than to promote good health. Moreover, for many, HP/DP lacks the drama associated with the high-technology crisis-care so often observed in many of our hospitals (as well as on most of our "medical drama" TV shows).
Turning to contemporary definitions of health, despite the emphasis on curing characteristic of Western health care delivery systems, stepping across both geographical and historical boundaries, the World Health Organization (WHO) has adopted a definition of health that resonates much more with Hygeia than with Asklepios.
For the WHO health is (1958, p. 459): "a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity." This definition obviously reflects the Hygienic notion that health is a positive state. It is interesting to note how the WHO approach reflects the thinking of non-Western cultures.
D. Some Non-Western Approaches
Sidney Kark, the South African/Israeli epidemiologist, quoted a Hindu physician thusly (1974, p. 11): "To the Hindu, health is harmony; [harmony is] being at peace with the Self, the community, God and the cosmos." This idea comprehends both balance with the outside world and balance within the person, as necessary for the achievement and maintenance of health.
The Taoist concept of health is much the same (Cohen). Kark, quoting Adair and Deuschle, also cited the Navajo concept of health. The similarities to the Eastern philosophies cited are striking:
"[When there is] balance between the individual and his total physical and social environment, as well as . . . balance between the supernatural and man . . . good health is the result; and upset in this equilibrium causes disease." How like the Greek followers of Hygeia (and again see Concept VII).
E. Approaching a Comprehensive Definition
In general, modern Western definitions of health do not give balance pride of place, to say the least. For example, The Random House Dictionary of the English Language, Second Edition, Unabridged defines health in part by its supposed relationship to disease (Flexner). Health first is characterized as "the general condition of the body or mind with reference to soundness or vigor," but also as, "freedom from disease or ailment." Disease too The Random House Dictionary defines in part by citing the supposed opposite of health: "a disordered or incorrectly functioning organ, part, structure or system of the body. . . ."
The WHO definition (see above) has been criticized as being utopian (Dubos; Kass). A more functional definition is that proposed by Kass (1981), namely, "the well-working of the organism as a whole" (p. 4). Other definitions of health too have stressed life functioning, for example seeing health as the "state of optimum capacity for effective performance of valued tasks" (Parsons, 1958, p. 168) or as "personal fitness for survival and self-renewal, creative social adjustment, and self-fulfillment" (Hoyman, 1967, p.189).
The 1988 (international) Consensus Statement on Exercise, Fitness, and Health defined health as (Bouchard, et al, p. 84): ". . . a human condition with physical, social, and psychological dimensions, each characterized on a continuum with positive and negative poles. Positive health is associated with a capacity to enjoy life and to withstand challenges; it is not merely the absence of disease. Negative health is associated with morbidity and, in the extreme, with premature mortality."
Included in a comprehensive definition of health promotion developed for the American Journal of Health Promotion (O'Donnell; for further discussion see chapter two) follows: "Optimal health is defined as a balance of physical, emotional, social, spiritual and intellectual health."
Taking into account all of these different approaches to a definition of health and many others not quoted here, a useful functional definition of health is perhaps as follows: "Health is a positive, balanced, state of being characterized by the best achievable physical, psychological, emotional, social, spiritual and intellectual levels of functioning at a given time, the absence of disease or the optimal management of chronic disease, and the control of both internal and external risk factors* for both diseases and negative health conditions."
This is the definition comprehended by Concept I (see chapter three). In virtually all of the definitions presented, health is indeed a state of being, and a measurable one at that.
* A risk factor is some environmental element, personal habit, or condition of living that increases the likelihood of developing a particular disease or negative health condition at some time in the future.