What is this article about?

In 1948, the WHO introduced a definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. This definition has been criticised over the past 60 years, and the criticism is increasing. This article describes the limitations of this definition and describes how it can be made more useful.

What are the limitations of the WHO definition?

 Most criticism on the WHO definition is about the word ‘complete’ in relation to wellbeing. He or she states that almost no one is healthy for most of the time. This is a problem, because this has lead medical technologies and drug industries to sell a lot of things that are supposed to increase “health”, and develop drugs for “conditions” that are not actually health problems. Also thresholds for interventions tend to be lower. The author suggest that this is due to the emphasis on complete physical wellbeing. 

The second criticism is that the demography of populations and the nature of diseases have changed considerably. In 1948, acute diseases presented the main burden of illness and chronic diseases led to death. However, there are now different disease patterns. Currently, ageing with chronic illnesses has become the norm. The healthcare system is under pressure, and this is also partly due to the WHO definition which seems to declare people with chronic diseases and disabilities as ill.

The third criticism on the definition is about the operationalisation. It is impracticable because ‘complete’ is not operational (not measurable).

What do we need?

The author suggests that the definition should be changed. The Ottawa Charter is one proposal, and emphasises social and personal resources as well as physical capacity. However, WHO has never accepted any proposal for change of their definition. It is also hard to redefine health, because it is complex; there are many aspects that need to be considered and there are many stakeholders. A discussion between Dutch experts about the definition of health was “the ability to adapt and self manage”. To be able to use this concept, it should be identified for the three domains of health: physical, mental, and social health.

Physical health

When an organism is healthy, the organism is capable of ‘allostasis’: maintaining physiological homeostasis through changing circumstances. When an organism experiences stress, it should be able to create a protective response, to reduce the potential for harm, and restore equilibrium. If this coping strategy is not successful then there is damage, called allostatic load. This eventually leads to illness.

Mental health

Mental health is described as ‘the sense of coherence’, which is a factor that contributes to successful coping, recovering from psychological stress, and prevent post-traumatic stress disorders. It is about understanding, managing and giving meaning to difficult situations. Being able to adapt and manage oneself improves subjective wellbeing and may result in a good interaction between mind and body. For example, patients with chronic fatigue syndrome who receive cognitive behavioural therapy show positive effects in terms of symptoms and wellbeing, as well as an increase in brain grey matter volume.

Social health

In the social domain, health is seen as people’s capacity to fulfil their potential and obligations, the ability to manage their life with some independence, and to be able to participate in social activities including work, despite having a medical condition. Patients with chronic illnesses who learnt to manage their lives better, reported improved self-rated health, less distress, less fatigue, more energy and less perceived limitations. Their healthcare costs also reduced!

How can we measure health?

Health measurements should relate to health as the ability to adapt and to self-manage. Operational tools include existing methods for assessing functional status and measuring quality of life and sense of wellbeing.

BulletPoints

• In 1948, the WHO introduced a definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. This definition has been criticised over the past 60 years, and the criticism is increasing. This article describes the limitations of this definition and describes how it can be made more useful.

• The second criticism is that the demography of populations and the nature of diseases have changed considerably. In 1948, acute diseases presented the main burden of illness and chronic diseases led to death. However, there are now different disease patterns. Currently, ageing with chronic illnesses has become the norm. The healthcare system is under pressure, and this is also partly due to the WHO definition which seems to declare people with chronic diseases and disabilities as ill.

• The author suggests that the definition should be changed. The Ottawa Charter is one proposal, and emphasises social and personal resources as well as physical capacity. However, WHO has never accepted any proposal for change of their definition. It is also hard to redefine health, because it is complex; there are many aspects that need to be considered and there are many stakeholders. A discussion between Dutch experts about the definition of health was “the ability to adapt and self manage”. To be able to use this concept, it should be identified for the three domains of health: physical, mental, and social health.