(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?
II. THE PURPOSES OF BEING HEALTHY
Regardless of the definition of health one might choose to use, what does health do for us? Herophilus, an ancient Greek physician who lived in Alexandria, Egypt, has been quoted by Sigerist (1941, p. 57): "When health is absent, wisdom cannot reveal itself, art cannot become manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied."
In 1787, Thomas Jefferson, who addressed so many subjects with so much wisdom, wrote: "Without health there is no happiness. And attention to health, then, should take the place of every other object. The time necessary to secure this by active exercises should be devoted to it in preference to every other pursuit. I know the difficulty with which a strenuous man tears himself from his studies at any given moment of the day; but his happiness, and that of his family depend on it. The most uninformed mind, with a healthy body, is happier than the wisest valetudinarian [person in poor health] (Foley, p. 402)."
The late, great "running doctor" George Sheehan, put it in a slightly simpler way (1989, p. 24): "Health makes for the happy pursuit of happiness and gives us a longer time to do it."
As Breslow said (1996): "[E]xpanding people's capacity to extend enjoyable life . . . constitutes health."
Donald Ardell, a leading contemporary developer and promoter of the concept of "wellness" (see below), considering the related question of the purpose of being well as well as healthy, took an even broader approach (Ardell, 1996, pp. 69-70): "Wellness is essentially a lifestyle that encompasses a set of principles, such as the belief in the values of making thoughtful, disciplined choices with respect to such issues as exercise and nutrition. It entails skills, such as a capacity for managing stress and functioning with a commitment to embracing personal as well as social responsibility. And, not last and surely not least, wellness can and must lead to a lifelong quest for insights and understanding, satisfaction, and excitement for the greatest quest of all, namely, making wise decisions about life's Meaning and Purposes."
"In summary, wellness offers those who seek to create their own form of a good life (rather than passively hoping it will happen) a broad set of guides for high levels of being. It is a concept for improving the chances for realizing and enjoying exceptional health. It promotes your chances for a satisfying and fulfilling life perceived as meaningful and filled with worthy purposes."
This approach emphasizes the incorporation of good health habits into one's everyday life (Gorin and Arnold; Jonas and Konner; Kassberg and Jonas).
With the beginning of the new Millenium there is an increasing amount of interest in personal health and health maintenance on the part of the general public. For example, there is the growth of self-care and alternative systems of care (Clark, C.C., 1999; Eisenberg, et al; Hagen; Wallis; Wolinsky, Chap. 10). This growth indicates on the part of some segment of the population considerable discontent with the present patterns of health care practice in the health promotion/disease prevention.
During the run-up to the introduction of the Clinton health care reform package in 1993, in public statements Hillary Rodham Clinton and others paid a good deal of attention to the importance of including a comprehensive set of health promotive/disease preventive services as part of the benefit package in any program finally adopted and implemented. The Clinton Health Plan was defeated by a powerful coalition of insurance, corporate, health care industry, and political forces unalterably opposed to it for a variety of pecuniary and political reasons. Nevertheless it was encouraging to see that a comprehensive group of HP/DP services was to have been included in its benefits package.
III. DEFINITIONS OF DISEASE AND ILLNESS
Wrapped up with the definition of health are, of course, the definitions of disease and illness. A classic medical dictionary, Blakiston's, took a precise, functional approach to defining disease (1956): "a failure of the adaptive mechanisms of an organism to counteract adequately the stimuli and stresses to which it is subject, resulting in a disturbance in function or structure of any part, organ, or system of the body."
Recall that in defining "health" Webster's Unabridged Dictionary called disease "uneasiness or distress" and "any departure from health." On the definition of disease, the Random House Unabridged Dictionary, like Blakiston's is much more precise (Flexner): "a disordered or incorrectly functioning organ, part, structure, or system of the body resulting from the effect of genetic or developmental errors, infection, poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors;"
Whatever its definition, however, disease is a biomedical concept. Disease is something that a health care worker finds. Illness, on the other hand, is a state of being; it is something the ill person feels (Downie, et al, pp. 10-12). As Eric Cassell once said (1976, p. 48): ". . . let us use the word 'illness' to stand for what the patient feels when he goes to the doctor and 'disease' for what he has on the way home from the doctor's office. Disease, then, is something an organ has; illness is something a man has."
Illness thus has social and psychological as well as biomedical components. One can have a disease without feeling ill, as in asymptomtic cancer; and one can surely feel ill without being diseased.
IV. SOME SOCIAL FACTORS IN HEALTH AND ILLNESS
The concept of the "sick role" elaborated by Talcott Parsons (1951; Wolinsky, Chap. 5) formed the basis of the first modern approach to extending our understanding of "non-health" beyond the biomedical model. Its central feature was relating the state of disease/illness to social roles. For Parsons: ". . . the sick role has four components: 1) the nonresponsibility of the individual for his or her condition, 2) the exemption of the sick individual from normal task and role obligations, 3) the recognition that being sick is undesirable and one should want to get well, and 4) the obligation to seek out competent help."
The strictly biomedical model of health and disease has been further challenged over the years since Parsons' time. As Engel said, for example, the biomedical model (p. 591): ". . . assumes disease to be fully accounted for by deviations from the norm of measurable biological variables. It leaves no room within its framework for the social, psychological and behavioral dimensions of illness."
Yet, as he also said, treatment directed at a biochemical abnormality does not necessarily restore health. This is because of discrepancies between the physical measurements and the psychological and social variables. Parsons' sick role model (1951) discussed briefly above, and its more modern variants as developed by Friedson and others (Wolinsky, Chap. 4), also has bearing on this concept.
Although there is much disagreement as to just what constitutes mental health and mental illness, derangements in psychic functioning have been shown to cause physical health problems, including death (Friedman). For example, a large body of research has demonstrated the effects of bereavement (Osterweis, Solomon, & Green), leading Engel to ask, "Is grief a disease?" His answer is, "Yes, if the grieving person is functioning badly" (p. 601). At the same time, the health care provider's own behavior is a major variable in the therapeutic interaction. (And of course, one aim of this book is to help bend that provider behavior itself in the direction of health, to make it more beneficial for patients and clients.) As Engel said (p. 599): "[T]he relationship between patient and physician powerfully influences therapeutic outcome for better or for worse. These constitute psychological effects which may directly modify the illness experience or indirectly affect underlying biochemical processes."
As Friedman noted (1990, pp. 4, 8): ". . . the relationship between personality and disease is not a simple one. People are complex, dynamic organisms [that] are constantly facing new environments, growing,and aging, and striving to maintain health. Understanding the relationship between personality and disease necessitates a sophisticated appreciation of the relevant issues. . . . In brief, [however], there is evidence that patterns of negative emotions are associated with illness, and there is evidence to deem it physiologically plausible that personality would play a causal role in disease."
Since health and illness are defined functionally, as noted sickness also can be seen both as a biological phenomenon and as a social role that carries with it certain rights and obligations (Brown, pp. 142-145). However, even when a person seems to have brought an illness upon themselves --- as in a careless self-induced personal injury or lung cancer caused by cigarette smoking --- we now know that rarely are they solely responsible for their condition (Breslow, 1996).
For example, the seriousness of a personal injury arising from a given automobile collision, even when one is driving drunk, is often influenced by external factors, e.g., the presence or absence of airbags in the automobile. Whether or not to smoke cigarettes is an individual decision. But in the overwhelming majority of cases that decision is made during the pre-teen or teen-age years, when a person is most susceptible to both tobacco company advertising and the relatively infinite availability of cigarette supply at relatively low prices. Nicotine in cigarettes is a highly addictive drug. Then once hooked, smokers are subject to the continuous manipulation of nicotine levels in cigarettes by the tobacco companies (Hurt, 1998).
Thus going beyond the individual to society as a whole, it is by now clear that social factors have a very significant impact on disease and health (Brown, 1989, Sect. One). Although much remains to be learned, the science of social epidemiology (Wolinsky, 1988, Chap. 1) has elucidated the relationship between states of health and illness and many social/societal characteristics. These include nationality, social class, race, employment status, occupation, behavior patterns, societal promotion of illness (by, for example, the tobacco companies), societal promotion of prevention (by, for example, governmental requirements for safe automobile design), and geography. It is the strategies of social ecology that attempt to influence this concatenation of health influences at the societal level in a positive direction (Breslow, 1996).
In the half-century since Parsons first offered his concept of the "sick role," as it is for the most part practiced in the United States, medicine still has trouble incorporating these formulations into its modus operandi.