What is health?
You would think a medical doctor would be able to answer that question easily. Try it out. Ask a doctor. In fact, ask anyone. I bet you’ll get different answers and I wouldn’t be at all surprised if you find that none of the answers are completely satisfactory.
I am aware of several different attempts to define health. None of them really work for me. This is quite a problem. I think a doctor’s job should involve healing. In other words, a doctor should help a patient to find health. If a doctor cannot clearly describe what health is then how can they know if they are doing a good job? How can they know if the treatments they are using are good treatments?
I started by consulting the standard textbook I used throughout medical school in Edinburgh – “Davidson’s Principles and Practice of Medicine”. The latest edition I have in my library is the 19th one (2002). It’s got 1274 pages. I started by looking up the index. Guess what? There is no index entry for “health”. I searched through the contents, the introduction, but, no, no description of health. Can the practice of medicine be conducted without understanding what health is?
What has happened is that we have focussed all our energies and efforts on understanding and dealing with disease. But if health is, as WHO say, “not merely the absence of disease or infirmity” then surely a doctor is not doing enough if he or she only deals with disease.
But how to understand health?
That’s the question that set me off on this particular journey of discovery. It’s a journey I am still on but I thought I would share with you some of the places I’ve visited along the way.
This is just a short introduction to this journey with a mention of some of the most important texts I’ve read along the way.
My first breakthrough was Hans Georg Gadamer’s “The Enigma of Health” (ISBN 0-8047-2692-2). He makes it clear that health is an experience and it is difficult to understand and articulate because actually it is not an entity. Think of it this way – disease manifests itself. It draws attention to its presence through pain, irritations, something not working as it should do. Health, on the other hand, does not draw attention to itself. When your hand is healthy you have very little awareness of it, but when you trap your thumb in a car door you are VERY aware of your thumb and that there is something wrong with it! I like this way of understanding health. It means that we have to understand health as an experience, a process, not as a thing, an entity. The implication of this is that health cannot be easily defined and measured.
Following on from this I read various books on the history of Medicine. What becomes clear from a historical perspective is that there is a developing story which leads right up to the present day.
Prior to say the 16th Century the accepted wisdom on health was that it was a balance of “humours”, and that disease was a result of the four humours becoming unbalanced, or was inflicted spiritually, either by an evil force (a witch for example), or by God (as a punishment). The big change occurred with the mass autopsies in the public Parisian hospitals. This lead to the development of “morbid anatomy”. Take a look at Rembrandt’s “Anatomy Lesson of Dr Tulp”. At this point disease became a thing, an entity which could be pointed to, described and measured. From that date on there has been an increasingly detailed focus on disease driven by technological innovation. We moved from a focus on organs to one on cells with the invention of the microscope. From cells to the chemical constituents of cells with laboratory equipment. And now to DNA. This whole narrative is one of focussing on disease, on the mechanics of disease and on smaller and smaller components of the human organism to understand the mechanics of disease. This has produced startling improvements in our capabilities. We can save lives in extremis much more now than we could. Whether its trauma, a heart attack, seizures, asthmatic attacks, or whatever, your chances of surviving such extreme disease are better now than they ever were. However, what it hasn’t produced is an overall reduction in the burden of suffering. Chronic diseases are on the increase around the world, old infections such as TB are on the up, new infections, “superbugs” emerge all the time. What we have achieved with this narrative is not enough.
The next step for me was to think, well, if an increasingly reductionist approach is not going to help, how can we take a more holistic view?
I encountered two important texts at this point.
The first text I came across was about the work of the French philosopher, Gilles Deleuze. One of his concepts which immediately grabbed me was his idea of the rhizome. The best way to understand this is that a rhizome functions as a web. Like the World Wide Web. It has no centre, no single trunk or stem (unlike the more predominant “arboreal” model – the tree with all its branching and branching). Another of his concepts which hit home for me was change. He points out that everything is always changing, and that if we want to understand anything we should try to see not what it “is” but what it is “becoming”. That’s where I got the “becoming not being” byline for this site. There’s one more of his concepts which changed my thinking about health – that we should focus on difference. Well, it strikes me that the best way to understand a patient is to see both the complex network of systems and functions within them and the complex network or web of interactions and influences in which they live – their physical, social and cultural environments or contexts. Secondly that I need to hear the patient’s story. A story is a dynamic. It comes from somewhere, and is going somewhere. A story is not an object, its a way of communicating an experience (both to others and to ourselves – narrative is how we make sense of our world). Thirdly, I need to understand what makes this patient different from everyone else. What is unique about them and how can they best be helped? This all made sense and lead to a holistic view rather than a reductionist disease-focussed view.
The second text I came across was “Crossing the Quality Chasm” from the Institute of Medicine (ISBN 0-309-07280-8). This is the final report of the Committee on the Quality of Health Care in America published in 2001. Believe it or not it was Appendix B that grabbed me! Here was a description of a scientific model of complexity. In particular, here is a description of something called a “Complex Adaptive System”. You can read more about that here.
These texts led me to explore more and more about complexity, and, specifically, about complexity science as it helps us understand the functioning of living organisms.
Here are my conclusion so far. This is how I understand health.
A healthy living organism is constantly adapting, continuously growing and can only be understood by including an examination of its interactions with others and with its environments.
So, here is how to understand and develop health –
This is the hero’s journey –
- responsiveness to change, resilience and the ability to cope with change, in short, adapt.
- constant growth, a drive to the realisation of potential, and the ability to do something new and to express oneself, in short, create.
- continuing interaction with others and with the environment, building connections, points of contact, loving and being loved, in short, engage.