Health is a complex concept. Historically, this would have been defined only as an absence of disease. In 1948, the World Health Organization (WHO) provided a definition of health:
‘’a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”
Is this definition still relevant? How did this definition move the discussion of health forward, and what is it lacking? According to Nobile, there are some positives. This definition created a shift in thinking of health simply as an absence of disease and attempted to provide a culturally neutral definition as a tool for evaluating living conditions across countries. This definition importantly tied health to human rights. As well as freedom from discrimination based upon a person’s characteristics. Nobile also suggests it ties the idea of health to the idea of peace among nations and cooperation among states. Further, it acknowledges the concept of self-determination and looks at multiple aspects of health rather than seeing health as only physical. (2014).
Nobile also had criticisms, however. The elements included are broad and subjective. The attributes may also be culturally defined and thus value/judgment laden i.e. the adherence to cultural norms is considered healthy. There is a risk of “medicalization of life” in pursuit of “complete” physical, mental and social well-being. This word – complete – is so wide as to be unattainable – no individual or healthcare system could ever meet the goal. Additionally, epidemiology and demographics have changed – the world’s population is older and more commonly living with conditions that would undermine this definition of health. Nobile also argues that health is “necessarily linked to socio-economic and environmental policies, which are not in the hands of the individual” and that a new definition of health must include these determinants of health. (2014).
Huber, et al. described the need for a more dynamic definition based upon the ability to “adapt and self-manage”, noting that the 1948 definition declares those with chronic disease or disability as not healthy and even further, by including the word “complete” leaves the vast majority of the world’s population as “unhealthy most of the time”. This word as the key descriptor of the state of health also creates difficulty with operationalization and measurement. (2011). (Smith, 2008).
Alternatives concepts and definitions proposed identify a perspective that includes systemic considerations. From the Ottawa Charter for Health Promotion: “Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities.” (Ottawa Charter of Health Promotion, 1986)
“Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities.” ~ Ottawa Charter of Health Promotion, 1986
Bircher, et al propose the Meikirch model which defines “Health is a dynamic state of well-being emergent from conducive interactions between an individuals’ potentials, life’s demands, and social and environmental determinants. Health results throughout the life course when an individual’s potentials – and social and environmental determinants – suffice to respond satisfactorily to the demands of life. Life’s demands can be physiological, psychosocial, or environmental and vary across individuals and contexts”. (2017).
It is this definition that we will delve into a little deeper. The Meikirch Model is a complex adaptive system (CAS) characterized by five components and ten complex interactions. The components are the Individual Determinants of Health which are two-fold: firstly the biologically given potential (BGP) and the personally acquired potential (PAP); the social determinants of health; the environmental determinants of health and finally, the demands of life. All five components interact with each of the other components to determine the state of health of the individual.
Consider first the components that make up the individual determinants. The BGP are the gifts that any individual is endowed with at birth. The PAP are the “physical, mental and spiritual abilities an individual can acquire” over the course of a lifetime. These may positively or negatively influence the individual’s ability to respond to the demands of life. These individual determinants of health are continuously interacting with one another, and are “immersed and surrounded by” society’s management of health. These are the social determinants of health. Examples would include laws set up for public welfare, or institutions for provision of education or health. The fifth component are the environmental determinants of health which include geographical location of the individual and the macro and local influences on health. Political climate and environmental issues are examples of some of these determinants.
I find this definition, which truly is a framework for health, to be useful in considering how to influence health. It provides varying possible points of intervention to address outcomes. The short-comings of the WHO definition are particularly acute, from my perspective, when considering disability. In my experience with Home Care, I have had the privilege of seeing individuals manage difficult conditions and live exceptionally well, in a manner that embodies health. Yet such individuals could not be described as having “complete” physical health as defined by the WHO. In contrast, through the Meikirch Model, this individual would be seen as meeting life’s demands with the appropriate support of systems within the social and environmental determinants of health. These would help to offset a limitation in that person’s BGP, PAP or both. I believe this definition gives better direction for influencing social policy and improved ability to set parameters to measure health outcomes. It provides a reconstitution of health toward the realities of living well as individuals with varying endowments within complex systems that may serve to support or undermine them.
References
Bircher, J., & Hahn, E. G. (2016). Understanding the nature of health: New perspectives for medicine and public health. improved wellbeing at lower costs. F1000Research, 5, 167. doi:10.12688/f1000research.7849.1
Bircher, J., & Hahn, E. G. (2017). Will the meikirch model, a new framework for health, induce a paradigm shift in healthcare? Cureus, 9(3), e1081. doi:10.7759/cureus.1081
Brook, R. H. (2017). Should the definition of health include a measure of tolerance? Jama, 317(6), 585-586. doi:10.1001/jama.2016.14372
Huber, M. (2011). Health: How should we define it? British Medical Journal, 343,(7817), 235-237. https://doi.org/10.1136/bmj.d4163 (link http://www.jstor.org/stable/23051314)
Nobile, M. (2014). The who definition of health: A critical reading. Medicine and Law, 33(2), 33. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27359006
Richard smith: The end of disease and the beginning of health. (2008). Retrieved from https://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/
World Health Organization (1986, November 21). Ottawa Charter for Health Promotion. Retrieved October 6, 2018 from http://www.who.int/healthpromotion/conferences/previous/ottawa/en/