Defining health in the twenty-first century

The question, “what is health”, has been pondered and debated for years (Brüssow, 2013). Human beings, by psychological necessity, navigate through the world by creating mental concepts or constructs to identify and measure their experiences (Kolb, 2015). It is this human need to conceptualize that fuels the longstanding debates to define things such as health, love, and success. Today I want to compare two attempts at defining health. The first, published in 1948, is the widely-accepted definition of health found in the preamble of the constitution of the World Health Organization (World Health Organization (WHO), 2014). The second, published by Bircher and Kuruvilla in 2014, is presented as the Meikirch Model of Health (Bircher & Kuruvilla, 2014).

Some scholars list the first principle in the WHO’s constitution as the complete definition of health (Huber, 2011). It states, “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 2014, p.1). However, there are additional principles in the preamble that can elaborate on this definition. Bircher and Kuruvilla (2014) discuss some of these additional principles in the introduction of their Meikirch Model of Health. To their list I add the principle related to the development of health. These additional principles are:

the enjoyment of the highest attainable standard of health is one of the fundamental

rights of every human being; informed opinion and active cooperation on the part of

the public are of the utmost importance; the ability to live harmoniously in a

changing total environment is essential to such [healthy] development; governments

have a responsibility for the health of their peoples which can be fulfilled only by the

provision of adequate health and social measures (WHO, 2014, p.1).

These principles present the definition of health as an individual’s complete state of wellness that develops when a person lives harmoniously in a changing environment. This complete state of wellness is a fundamental right for all and is the responsibility of the individual and of the government.

The WHO definition of health has not been updated since 1948. Many scholars believe this definition should be modernized, rationalizing the need for this change with several critiques (Huber, 2011). Huber states that in 2009 health experts gathered at an international conference in the Netherlands to discuss the limitations of the definition and to suggest ways to modernize it. They highlighted three main criticisms of the WHO definition.

The first criticism is that the quest for complete well-being “unintentionally contributes to the medicalization of society” (Huber, 2011, p. 235). In this definition of health, individuals become increasingly medically dependent and in this way the definition serves the needs of the medical and pharmaceutical industries over the needs of the public.

The second criticism is that the state of complete well-being and absence of disease is unattainable for most humans (Huber, 2011).  The author reports that many people, especially as they move through the aging process, report feeling healthy despite living with chronic disease. This idea of feeling healthy while living with a chronic disease is excluded from WHO’s definition of health.

The third criticism is that the definition of health as complete well-being is too vague and does not allow for the measurement of health (Huber, 2011). Brussow (2013) points out that WHO has created a measurement tool to capture an individual’s health state.  The International Classification of Functioning, Disability and Health surveys assess “an individual’s health state by asking for mobility, self-care, pain, cognition, interpersonal activities, vision, sleep and energy and affect. The answers go into a single metric reaching from death (0) to perfect health (1)” (Brüssow, 2013, p. 343). This metric is not currently being used operationally to measure individual health, and so the third criticism still stands true today.

Bircher and Kuruvilla (2014) also discuss the three critiques presented at the 2009 conference in their description of the Meikirch Model of Health. In addition, they point out that the definition does not give much guidance on how to fulfill the complete state of well-being. The authors present a modern definition of health, known as the Meikirch Model of Health, that they believe addresses the three main criticisms of the WHO definition of health. They also believe the model can be used as a framework to guide the operation of healthcare by an interprofessional collaborative team.

The Meikirch Model of Health states that “health is a state of well-being emergent from conducive interactions between individuals’ potentials, life’s demands, and social and environmental determinants” (Bircher & Kuruvilla, 2014, p. 368).  This definition moves away from the concept of complete well-being and absence of disease and infirmity, allowing for individuals to be both healthy and living with a chronic disease. This definition also demonstrates that health is a result of the interactions between an individual’s potential, their environment, and the social conditions in which they live. This description makes it clear that health is the responsibility of many. Policy-makers, regulators, elected officials, healthcare providers, educators, and civilians all play a role in shaping the environment and the social determinants of health, and as such are responsible for the health of a population and the individuals therein. In the same vein, the Meikirch Model moves away from society’s medical dependency on health as suggested in the WHO definition. Bircher and Hahn (2017) describe in detail how the Model can be used to guide this type of intersectoral collaboration.

In a published commentary on the Meikirch Model, Nauvoma (2014) argues that the model puts too much emphasis on the role of the individual and their potentials in this definition of health. Her intention in this critique is honourable; to “protect those who have limited opportunities to ‘use their biologically given and personally acquired potentials’ or to entertain their rights of healthy living standards” (Naumova, 2014, p. 397). I would agree individuals living in resource-poor communities have a harder time obtaining the necessary environmental and social resources needed to achieve a state of well-being. Unlike Nauvoma, I interpret the Model to mean that when the individual requires additional resources to achieve a state of well-being, social and environmental conditions must be modified to help the individual achieve a healthy life. In other words, I see each of these elements as holding equal weight in the model and that deficiencies in one area can be compensated by the other areas.  I interpret this with the assumption that many stakeholders are involved in the modification of social and environmental factors.

What is still not clear to me is how the Meikirch Model allows for the measurement of health. Bircher and Kuruvilla (2014) identify this as a limitation of their model and offer individual and population level variables to consider for measurement. However, they stop short of providing the tools to measure these variables.

Today’s discussion of health requires the voice of many stakeholders, not just medical professionals and patients, but also those concerned with environmental and social determinants of health. Although the WHO constitution mentions the responsibility of government to provide measures to support health, I believe the Meikirch Model of Health more accurately describes how environmental and social conditions interact with an individual’s potential to achieve a state of well-being. The development of measurement tools to assess the state of health for individuals and populations will help to improve the usefulness of the Model.

References

Bircher, J., & Hahn, E. G. (2017). Will the Meikirch Model, a New Framework for Health, Induce a Paradigm Shift in Healthcare? Cureus. https://doi.org/10.7759/cureus.1081

Bircher, J., & Kuruvilla, S. (2014). Defining health by addressing individual, social, and environmental determinants: New opportunities for health care and public health. Journal of Public Health Policy, 35(3), 363–386. https://doi.org/10.1057/jphp.2014.19

Brüssow, H. (2013). What is health? Microbial Biotechnology, 6(4), 341–348. https://doi.org/10.1111/1751-7915.12063

Frenk, J., & Gómez-Dantés, O. (2014). Designing a framework for the concept of health. Journal of Public Health Policy, 35(3), pp. 401–406. https://doi.org/10.1057/jphp.2014.26

Huber, M. (2011). Health: How should we define it? British Medical Journal, 343(7817), 235-237. https://doi.org/10.1136/bmj.d4163

Kolb, D. A. (2015). Experiential Learning: Experience as the Source of Learning and Development (2nd ed.). Upper Saddle Ridge, NJ: Pearson Education Inc.

Naumova, E. N. (2014). A cautionary note for population health: Disproportionate emphasis on personal responsibility for health and wellbeing. Journal of Public Health Policy, 35(3), pp. 397–400. https://doi.org/10.1057/jphp.2014.23

World Health Organization. (‎2014)‎. Constitution of the World Health Organization. In Basic documents (48th ed.). World Health Organization. Retreived from http://www.who.int/iris/handle/10665/151605.