Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India. )
Varun Arora  ( Department of Community Medicine, Pt BDS PGIMS, Rohtak, india )
Madhur Verma  ( Department of Community/Family Medicine, All India Institute of Medical Sciences, Bathinda )
Vijay Kumar  ( Department of Geriatric Medicine, AIIMS, New Delhi, India. )

The World Health Organization’s definition of health has remained unchanged for over seventy years. An ageing population, advances in prevention and management, as well as increasing impact of non-communicable diseases have led to the need for a novel definition of health. We suggest health to be “a sustainable state of optimized physical, social and mental well-being, and not merely the absence of acute disease or infirmity”.

Keywords: Chronic disease, geriatric health, mental health, non-communicable disease, physical health, social health, World Health Organization

 

Limitations of the Classic Definition

 

The definition of health has not changed for over seven decades. The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.¹

Many changes have taken place in the field of health since this definition was formalized in 1948. Morbidity and mortality patterns have changed; means of prevention and treatment have evolved; and our ability to screen, forecast and diagnose disease and its complications has improved. These, and other factors, have led to criticism of the current definition, and call for change.^2-4 In 1984, WHO revised the definition of health to "the extent to which an individual or group is able to realize aspirations and satisfy needs and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources, as well as physical capacities".⁴ However, this description has not gained traction among medical circles.

When the definition was agreed upon in 1948, the main health challenges facing the world were acute and infectious in nature. Since then, life expectancy has increased markedly, and the prevalence of non-communicable diseases has risen manifold. This has led to a large number of persons who live with well managed disease, albeit without disability, as well as those with disability but perfect emotional and social health.  These individuals feel “healthy”, even though they do not have “absence of disease”.⁵

On the other hand, there are many unhealthy individuals who state that they enjoy “absence of disease” because their either have subclinical disease, refuse to acknowledge their illness, or decline to accept appropriate medical care.⁶ Such misinformed misadventures ultimately lead to complications which could easily have been avoided. This is especially true in chronic care segments such as endocrinology, oncology and neuro-psychiatry.

Another change that has occurred in the last few decades pertains to environmental health. We have gradually understood the reciprocal relationship between our activities and the health of our environment. It is possible that actions taken to maintain short term health (for example, forest burning to achieve social or financial wellbeing, or use of carbon-emitting technology to maintain biomedical health) may lead to adverse long-term outcomes.⁷

 

A Challenge for the Profession

 

On one hand we have individuals who feel healthy, though they do not meet WHO’s criteria. At the other end of the spectrum are persons who self-report health due to ignorance, whether willful or otherwise, but are on a trajectory towards disease or infirmity. Any attempt at creating a novel idea of health should take them in to account.

How can we modify the definition of health, in such a way as to address these issues, while keeping the sempiternal philosophy of the existing definition intact? How can we craft a definition that retains its classic appeal, while ensuring contemporary relevance?

 

Creating a Contemporary Classic

 

We use the words ‘sustainable’ and ‘optimized’ to construct such a description. Sustainable implies “a situation which can be maintained, or defended, at a certain rate or level”.⁸ Optimization means “best or most effective use of a situation or resources”.⁹ If an individual has been able to optimize his/her physical, mental and social well-being with the assistance of interventions such as lifestyle modification, drugs and devices, this should be considered a state of health. At the same time, health should be sustainable. A person who claims to enjoy good health as his glucose levels have fallen due to renal impairment, for example, cannot be considered healthy.¹⁰ Similarly, an individual with type 1 diabetes, hypothyroidism or hypertension, who claims to be well without insulin, thyroxine or blood pressure lowering therapy respectively, cannot be healthy as this state will not be sustainable in the long run.

We therefore suggest a modern definition: Health is a sustainable state of optimized physical, mental and social wellbeing, and not merely the absence of acute disease or infirmity.”

 

A Small Step for Health

 

The geriatric age group, and those living with chronic disease, are bound to grow in coming years.  Our rubric covers the needs of hitherto excluded members of society, without harming the needs of proactive health management. It suggests that health is a dynamic, long-term process as well as goal, instead of a static point –of-contact definition. Sustainability includes aspects of environmental health, financial prudence and resource husbandry, apart from alluding to a long-term focus on maintenance of health.  Optimization allows a fluid and “broad spectrum” approach to health, instead of a closed, binary thought process. Optimal mental and social well-being should be defined by both the individual person and the health care team, through a process of shared decision making. Inclusion of the term ‘acute’ allows persons living with chronic disease to assert their rightful semantic claim on health.

We hope that our suggestion will help promote discussion and debate on semantics, while offering a pragmatic and practical solution towards finding appropriate nomenclature for health.

 

References

 

1.      Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of WHO, no. 2, p. 100) and entered into force on 7 April 1948.

2.      Huber M, Knottnerus JA, Green L, van der Horst H, Jadad AR, Kromhout D, et al. How should we define health? BMJ. 2011;343: d4163.

3.      Charlier P, Coppens Y, Malaurie J, Brun L, Kepanga M, Hoang-Opermann V, et al. A new definition of health? An open letter of autochthonous peoples and medical anthropologists to the WHO. Eur. J. Intern. Med.. 2017;37:33-7.

4.      World Health Organization. Regional Office for Europe (1984). Health promotion: a discussion document on the concept and principles: summary report of the Working Group on Concept and Principles of Health Promotion, Copenhagen, 9–13 July 1984 (ICP/HSR 602(m01)5 p). Copenhagen: WHO Regional Office for Europe.

5.      Kalra S, Das AK, Baruah MP, Unnikrishnan AG, Dasgupta A, Shah P, et al. Euthymia in diabetes: Clinical evidence and practice-based opinion from an international expert group. Diabetes Ther. 2019;10:791-804.

6.      Peyrot M, Burns KK, Davies M, Forbes A, Hermanns N, Holt R, et al. Diabetes Attitudes Wishes and Needs 2 (DAWN2): a multinational, multi-stakeholder study of psychosocial issues in diabetes and person-centred diabetes care. Diabetes Res Clin Pract. 2013;99:174-84.

7.      Kalra S, Kapoor N. Environmental Endocrinology: An Expanding Horizon. Endotext [Internet]. 2021 Mar 14.  Available at: https://www.endotext.org/section/tropical-endocrinology/. Last accessed on 01 May 2021

8. Sustainable: Available at: https://www.google.com/search? q=dictionary&rlz=1C1CHBF_enIN824IN824&oq=dictionary&aqs=chrome..69i57j0j0i433l3j0j0i433l3.3012j0j7&sourceid=chrome&ie=UTF-8#dobs=sustainable Last accessed on 01 May 2021

9.      Optimization. Available at: https://www.google.com/search? q=dictionary&rlz=1C1CHBF_enIN824IN824&oq=dictionary&aqs=chrome..69i57j0j0i433l3j0j0i433l3.3012j0j7&sourceid=chrome&ie=UTF-8#dobs=optimization Last accessed on 01 May 2021

10.    Kalra S, Singal A, Lathia T. What’s in a name? Redefining type 2 diabetes remission. Diabetes Ther. 2021: 12, 647–654.