Feature

Completely healthy, utterly unattainable?

The WHO definition of health frees us from a narrow focus on disease, offering a positive vision of health. Or does it? Simon Dyson begs to differ

“Health is not merely the absence of disease or infirmity but a complete state of physical, mental and social well-being.”

How many times in how many essays have students reached for this definition of health, the better to open their assignments? It offers, the argument goes, a positive definition of health not a negative one. With its emphasis on mental and social dimensions it carries an implicit criticism of the biomedical model of cure not care, of professional expertise not lay community skills, of the technical fixes of drugs and surgery, and of investigations which look at parts (X-rays, urine and blood samples) not at the whole.

The critical look at biomedicine is certainly important. In that it mentions disease (rather than death from disease) it could be argued to redress some balance in favour of women since although women live longer than men they tend to suffer more ill-health during their lives. By including the mental dimension it provides a means of breaking the taboo which still arguably prevents full and open public discussion of mental ill-health. And by introducing social aspects of well-being, the WHO definition could be said to offer the chance to refocus our thoughts (and hopefully actions) on to economic and environmental causes of ill-health. But this brings us to the first of several important criticisms of the WHO definition.

Because it is a global definition, it has to be all things to all people. Like many international agreements it is couched in sufficiently broad terms as to have many possible interpretations. The socialist might see in ‘social’ a call for an equitable distribution of income and wealth, and for co-operative not competitive social relationships. The liberal might on the other hand see little more than ‘sociability’, having good community networks, or indeed, simply making friends. The conservative could interpret ‘social’ as an issue of conformity - that it is healthy to conform to ‘normal’ (for which read conservative) values. In this definition ‘anti-social’ can then mean anything with which the conservative disagrees.

The second criticism is that the definition can be read as an invitation to debate what we mean by positive well-being. The difficulty with this is that it is only more affluent groups (whether inhabitants of the industrial Northern countries, or the middle classes within individual societies) who have the resources to engage freely in that debate. For others, the struggles for employment, family and shelter have, of necessity, to take priority. Since not all have the same opportunities to decide what constitutes positive health, the debate cannot be said to be genuinely democratic. The danger is then that what comes to be seen as ‘positive health’ only encompasses the views of the affluent white middle-classes.

On the other hand, the ‘absence of disease and infirmity’ is much more clearly based on factors we can know about. We know that a poor diet undermines the immune systems of those with insufficient to eat and leaves them more vulnerable to infectious diseases. Thus the persistence of measles in developing countries; the return of diphtheria to Russia as liberal economies create new classes of poor; and the return of tuberculosis to the UK among, for example, homeless people. We know many diseases are transmitted through infected water and poor sanitation. Thus the persistence of cholera in developing countries, and the increasing incidence of cases of dysentery in this country as we move from water as a right, free at the point of consumption, to water as a commodity, regulated by meters, with a positive disincentive to wash hands, clean food preparation areas or flush toilets. The WHO definition invites us to debate ‘health’ which we cannot know. But at the same time it invites us to play down ‘absence of disease and infirmity’ which we can know, and about which action, nationally and globally, could be taken.

The final criticism of the WHO definition concerns its apparent popularity with nurses, therapists and health promoters. Medicine, so the argument goes, is merely about establishing the absence of disease and infirmity. Nursing, therapy and health promotion seek to move beyond this and establish ‘positive health’. But does this represent a convenient stick with which to beat the medical profession? Is ‘health-as-a-positive’ an occupational strategy to move nursing, therapies and health promotion out from the shadow of medicine? Is it a strategy to increase the status of these other health professions and health care professionals? If so, then perhaps we should regard ‘positive well-being’ with suspicion, for the professional middle-classes may have much more to gain from its adoption than those whose life pressures and lack of resources exclude them from the debate about precisely what well-being is. Time too, perhaps, to stop revering the WHO definition overall, and subject it to critical review.