Portal de Periódicos da CAPES

In search of health

2009; Wiley; Volume: 15; Issue: 4 Linguagem: Inglês

10.1111/j.1365-2753.2009.01263.x

1365-2753

Richard Smith, Laura O’Grady, Alejandro R. Jadad,

Historical and modern epidemiology studies

Journal of Evaluation in Clinical PracticeVolume 15, Issue 4 p. 743-744 Free Access In search of health Richard Smith, Richard Smith Editor-in-Chief, Cases Journal, London, UKSearch for more papers by this authorLaura O'Grady, Laura O'Grady Postdoctoral Fellow, Centre for Global eHealth Innovation; Department of Health Policy, Management and Evaluation; Faculty of Medicine, University of Toronto; and University Health Network, Toronto, Canada M5G 2C4Search for more papers by this authorAlejandro R. Jadad, Alejandro R. Jadad Professor, Centre for Global eHealth Innovation; Department of Health Policy, Management and Evaluation; Dalla Lana School of Public Health; Faculty of Medicine, University of Toronto; and University Health Network, Toronto, Canada M5G 2C4Search for more papers by this author Richard Smith, Richard Smith Editor-in-Chief, Cases Journal, London, UKSearch for more papers by this authorLaura O'Grady, Laura O'Grady Postdoctoral Fellow, Centre for Global eHealth Innovation; Department of Health Policy, Management and Evaluation; Faculty of Medicine, University of Toronto; and University Health Network, Toronto, Canada M5G 2C4Search for more papers by this authorAlejandro R. Jadad, Alejandro R. Jadad Professor, Centre for Global eHealth Innovation; Department of Health Policy, Management and Evaluation; Dalla Lana School of Public Health; Faculty of Medicine, University of Toronto; and University Health Network, Toronto, Canada M5G 2C4Search for more papers by this author First published: 23 July 2009 https://doi.org/10.1111/j.1365-2753.2009.01263.xCitations: 2AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL We are grateful to be asked to contribute to this volume that considers – and tries to broaden – thinking on health. Our qualifications for contributing are small but need to be described. Two of us (AJ and LOG) tried to start a conversation on how health should be defined through an editorial in the BMJ, an entry in Wikipedia and a Facebook group in 2008, 60 years after the birth of the World Health Organization (WHO) [1]. The third one of us (RS) wrote a blog on 'The end of disease and the beginning of health', which is cited in the first article in this special issue and argued, somewhat flippantly, that we should think much more about health and less about disease [2]. Indeed, having a 'disease-led health system' may be increasingly counterproductive when many patients, particularly elderly ones, have multiple diseases but are concerned less about their diseases and more about personal, family and social issues. In 2002, RS also wrote: 'Is it possible to be severely disabled, in pain, close to death, and in some sense "healthy"? I believe it is'[3]. Our method in writing this piece has been to read the articles in this issue, revisit our own writings and reactions to them, and bring in other material we have been reading. Our general message is to welcome the articles in this issue, urge ongoing collaboration around the thinking about health and disease, and hope that we can move beyond the narrow confines of learned journals into a broader arena. We are unconvinced that there are any experts when it comes to debates on health, or that health could be defined. In fact, we agree with a philosopher-psychiatrist who recently said to one of us (RS): 'It's impossible to define health. It's like trying to describe time. It can't be done. It's a "higher order" question.' Most of the important things in life – love, freedom, charity – can't be operationally defined, but it's still worth attempting descriptions to deepen our understanding of these virtues. Health may be especially important to try and describe in that we are devoting huge amounts of resources to its pursuit. Are we using those resources – which might be devoted to other benefits including international aid, education, housing, and the arts – wisely? Upon review of submissions we noted that all but one of the six were single authored. This, coupled with the lack of collaboration in a previous attempt to define health [4] has led us to ponder whether this task is better suited to the individual. Or are only individuals interested in defining health? We wonder what kind of paper would have been produced if all seven of the authors had collaborated on one version. We also noted that in three of the papers the authors chose to present their ideas within the context of a particular illness (psychiatry, diabetes and environmental illness), which may limit their applicability to the overall concept of health. However, everyone who has contributed to this issue seems to agree that the first half of the infamous WHO definition of health –'a state of complete physical, mental, and social wellbeing'– is unhelpful. It is an aspiration that implies that anything less than such a state is 'unhealthy'. Most of us would be unhealthy most of the time with this definition. The other component of the definition, focused on 'the absence of disease or infirmity' may be driving countries to spend an ever increasing proportion of their resources on 'health care'. But the WHO is the world's leading health body. Should we be persuading it to rethink and adopt a more realistic definition of health? Or is it right that a United Nations body should have such a grand target, even if it is Utopian? Do we actually need a definition of health? Is it possible to define it? Could the attempt at definition be counterproductive? If the question is, 'what is the definition of health?' the answer may very well be 'it depends'. Perhaps the definition should depend on the context in which it is being used. For example, the legal definition of insanity is not the same as the medical definition. Contributors to this issue, however, seem to agree that health is definable, multidimensional and complex. Stephen Lewis [5] asks us to expand our biological concepts of health, pointing out that biology does not concentrate on individuals but on species, populations, and even gene pools. Stefan Topolski [6] suggests that 'maximum health may be represented by maximum complexity', an attractive idea except that it might imply that old age is inevitably associated with poor health. We like David Katerndahl's [7] argument that we should think of health in non-linear terms; it's perhaps one of medicine's failures that much of its theory and evidence is based on the world being linear when it isn't. Helen Cooper and Robert Geyser [8] emphasise that this failing may be aggravated by the worldwide transition from acute to chronic care, illustrating how embracing complexity theory may improve the management of patients with diabetes. Fiona Coyle illustrates how the traditional biomedical model of sickness and health cannot cope with the complexity of the poorly defined environmental illness and shows how complexity theory can help us better understand the conditon. (9)"World is crazier and more of it than we think, Incorrigbly plural," writes the poet Louis MacNeice. Recognising the role played by personal values also leads us away from the idea that there can be some global standard agreement on what constitutes health. For some people – for example, athletes and explorers – physical capacity might be essential, while for others physical capacity could be unimportant if they can read and listen to Schubert or perhaps communicate with their God. It's this recognition that we value different aspects of what might be called 'health' that undermines the concept of quality adjusted life years (QALYs) that depends on our capacity to define yet another construct – quality. In addition, there seems to be agreement among contributors to this issue that health can't be thought of as purely a property of individuals. We as individuals cannot be healthy if our families, friends, communities, countries and planet are unhealthy. This complicates any attempt at definition because it implies defining what constitutes a healthy community, country, or planet. Are communities or countries that have wide inequalities in life expectancy or infant mortality – which is most communities and countries – unhealthy? Are countries that stifle free expression healthy? Here health seems to begin to occupy some of the same territory as politics, something that many would regard as dangerous. All contributors also appear to recognize that adaptation is an important component of health. With something like the almost divine WHO definition of health we can but fall short. Yet, as Joachim Sturmberg [10] shows, people can react very differently to different insults. We can see people disabled by problems that seem minor; while others seem to have fulfilling lives while suffering very severe physical problems. And perhaps a very important component of health is how we as individuals and societies respond to death. For Epicurus and the ancients 'The art of living well and dying well are one'. Montaigne agreed: 'Death is one of the attributes you were created with; death is part of you. Your life's continual task is to build your death'. Yet as Ivan Illich argued so forcefully, modern medicine seems launched into an expensive, doomed, misguided, and 'unhealthy' campaign to defeat death. [11] Every society has created in myth its version of the nightmare of immortality accompanied by physical and mental decay, but in the western world we are creating it for real. Consider this quote from Lewis Lapham, the both wise and witty editor of Harpers: 'I know that dying is un-American, nowhere mentioned in our contractual agreement with providence, but to regard the mere fact of longevity as the supreme good – without asking why or to what end – strikes me as foolish, a misappropriation of time, thought, sentiment, electricity, and frequent-flier miles. Of the $2.4 trillion assigned last year to the care and feeding of our health-care apparatus, a substantial fraction paid the expenses of citizens in the last, often wretched, years of their lives. Who benefits from the inventory of suffering gathered in the Florida storage facilities?. . . Absent a coming to terms with death, how do we address the questions of environmental degradation and social injustice certain to denominate the misfortunes of the twenty-first century?' Ironically, it may be that the true route to health lies in us as individuals and societies developing a much healthier attitude to death, the inevitability that awaits us all. The ancients knew what we have forgotten. We may ponder the following, 'if a definition of health is said in the forest, does anyone find it useful?' Humans tend to like to label and measure. It is how we make sense of our world. However, we sometimes find ourselves in a bind when we know something exists but cannot measure it. We all know health exists, but we may never know how to define and measure it, which we may just have to accept. Although we have not had much success so far with our attempts to encourage a conversation on what is health, we urge readers of this journal to join our Facebook group and stimulate the conversation. The URL is: http://www.facebook.com/profile.php?id=727567149&v=info#/group.php?gid=51641068791 References 1 Jadad, A. R., O'Grady, L. (2008) How should health be defined? British Medical Journal, 337, a2900. 2 http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/ (accessed 2 July 2009). 3 Smith, R. (2002) Spend (slightly) less on health and more on the arts. British Medical Journal, 325, 1432– 1433. 4 http://blogs.bmj.com/bmj/2008/12/10/alex-jadad-on-defining-health/ (accessed 2 July 2009). 5 Lewis, S. (2009) Seeking a new biomedical model. How evolutionary biology may contribute. Journal of Evaluation in Clinical Practice, 15 (4), 745– 748. 6 Topolski, S. (2009) Understanding health from a complex systems perspective. Journal of Evaluation in Clinical Practice, 15 (4), 749– 754. 7 Katerndahl, D. A. (2009) Lessons from Jurassic Park: patients as complex adaptive systems. Journal of Evaluation in Clinical Practice, 15 (4), 755– 760. 8 Cooper, H. C. & Geyer, R. (2009) What can complexity do for diabetes management? Linking theory to practice. Journal of Evaluation in Clinical Practice, 15 (4), 761– 765. 9 Coyle, F. (2009) 'It just doesn't seem to fit'. Environmental illness, corporeal chaos and the body as a complex system. Journal of Evaluation in Clinical Practice, 15 (4), 770– 775. 10 Sturmberg, J. P. (2009) The personal nature of health. Journal of Evaluation in Clinical Practice, 15 (4), 766– 769. 11 Illich, I. Limits to Medicine: Medical Nemesis – The Expropriation of Health. Harmondsworth, Penguin, 1977. Citing Literature Volume15, Issue4August 2009Pages 743-744 ReferencesRelatedInformation