WHO’s 1948 landmark definition of health as “complete physical, mental and social well-being, and not merely the absence of disease or infirmity” marked an important first step in redefining approaches to health and health care (Bradley et al., 2018; Brook, 2017; Huber, 2011; Government of Canada, n.d.; McCartney et al., 2019; Oleribe et al., 2018; Sartorius, 2006). The recognition of factors outside of disease created new conceptualizations of
what it means to be healthy and, for the first time, offered an opportunity to consider a person as more than their diagnosis (Sartorius, 2006). However, despite its progressive nature, this definition has seen little change in the past 70+ years (Huber, 2011; McCartney et al., 2019). Its relevancy in modern health research, promotion, and achievement has been called in to question given, among other factors, the changing nature of illness (Bigham & Omole, 2021; Bradley et al., 2018; Government of Canada, n.d.; Huber, 2011; McCartney et al., 2019; Sartorius, 2006).
There exist many criticisms in current literature and media of WHO’s 1948 definition. A few common themes (discussed below) include speaking in absolutes, the use of scales and standards, and ignoring the role of individual perception when defining health. In examining these, suggestions can be made for redefinition and practice improvements.
In its definition WHO uses the word complete. Possibly meant to seem wholistic, use of such an absolute term instead infers that health is binary, (you are, or you are not healthy), rather than existing along a continuum where each dimension of health (physical, social, mental, and others have added emotional) are present, at different and changing levels, and not necessarily all at one time (Bradley et al., 2018; Huber, 2011; McCartney et al., 2019; Oleribe et al., 2018). Rather, each dimension may exist in balance with one another, exhibiting reciprocal influence, in a way that remains largely positive (Bigham & Omole, 2021; Government of Canada, n.d.; McCartney et al., 2019; Oleribe et al., 2018). Additionally, while aspirational, the use of complete presents health as largely unattainable. This view risks demotivating individuals whose active input and involvement is critical in modern health promotion (McCartney et al., 2019).
An additional semantic misstep comes from WHO’s use of not merely when speaking of the absence of disease. This implies that the absence of disease remains a prerequisite for health and excludes a significant number of individuals who might otherwise consider themselves healthy if not for the presence of illness (Bradley et al., 2018; Oleribe et al., 2018).
By dealing in absolutes, WHO has also been criticized as (unintentionally) contributing to the further medicalization of society, including the prevailing belief that health is the responsibility of the medical field. This view ignores the importance of an individual’s own behaviours and motivations, and the influence of health determinants, and perpetuates the assumption that health is achieved through prescription medication and surgery (Bigham & Omole, 2021; Huber, 2011; Oleribe et al., 2018; Sartorius, 2006). Medication can and should remain a tool in the achievement of health, but it cannot and should not be the only tool (Bigham & Omole, 2021). And, while medical professionals have a key role to play in health promotion and reform, (sustainable) change cannot be achieved in a vacuum and will require collaboration across sectors (Bigham & Omole, 2021; Bradley et al., 2018; Brook, 2017; McCartney et al., 2019, Sartorius, 2006).
A second common criticism is that WHO’s definition implies the use of scales and standards. In 1948 however, and still today, few universally accepted or enforced standards and scales measuring social and mental wellness were/are in use (Brook, 2017). Additionally, few, if any, tools currently exist which measure an individual’s capacity to cope, an important component of health to be further discussed below (Huber, 2011). Scales and standards are undoubtedly useful as they provide data on which to base policy, inform health programs and target investment dollars (Brook, 2017; Government of Canada, n.d.; Huber, 2011; McCartney et al., 2019). Regardless of utility however, there use in this context is limited. There exist multiple factors (culture, religion, race, personal history, coping, etc.) which make health a uniquely subjective experience (Brook, 2017; Huber, 2011; McCartney et al., 2019). As such, current measurement tools cannot be applied consistently and, unlike easily quantifiable measures like mortality rate or incidence of chronic disease, do not provide a complete picture (Bradley et al., 2018). The term complete itself also cannot be definitively measured, making its application to research and treatment challenging, if not impossible (Huber, 2011).
WHO’s definition has also been widely criticized for its failure to account for the importance of individual perception of health in relation to unique history, environment, and motivations and the influence of developed skills, coping behaviours, and feelings of autonomy (Bigham & Omole, 2021; Bradley et al., 2018; Brook, 2017; Huber, 2011; McCartney et al., 2019; Sartorius, 2006). Technological change, population aging, and increased incidence of chronic conditions, have fueled a shift in care to (chronic) disease management and prevention. Humans are living with illness and for much longer, and as such, have developed an improved capacity to cope and thrive in the face of physical, emotional, and social challenges. These advancements, combined with positive perception, have created the current reality where health is something independent of and coexisting with disease (Bradley et al., 2018; Bigham & Omole, 2021; Huber, 2011; Sartorius, 2006).
Taking in to account these criticisms, how do we create a contemporary definition of health? Looking again to current literature and media, suggestions abound.
Sartorius, as an example (2006) defines health as “a state of balance, [or] equilibrium, that an individual has established within [them]self and between [them]self and [their] social and physical environment” regardless of the presence or absence of disease.
McCartney et al. (2019) agree, defining health as “a structural, functional, and emotional state that is compatible with effective life as an individual and as a member of society,” further asserting that loss of some function or ability (as with aging) does not have to mean a loss of health. The experience of (negative) health events does not matter as much as the capacities that these events create (McCartney et al., 2019).
Similarly, the Public Health Agency of Canada describes health as “the capacity of people to adapt to, respond to, or control life's challenges and changes,” considering individual and collective factors within and outside of the health system (Government of Canada, n.d.).
Huber (2011) and Bigham and Omole (2021) suggests being healthy involves the capacity to fulfill potential, manage obligations, and demonstrate some degree of independence, self-efficacy, and self worth. While, Bradley et al. (2018) believe health sees the integration of mind, body, and spirit.
What is clear is that modern conceptualizations must consider health as an asset. Health is both a resource and capacity as well as an outcome (Bradley et al., 2018; Government of Canada, n.d.; Huber, 2011; McCartney et al., 2019; Oleribe et al., 2018). Health is both a journey and a destination. By defining health in this way, greater acceptance can be given to the idea that an individual can be considered healthy despite, disease (Bigham & Omole, 2021; Bradley et al., 2018; McCartney et al., 2019; Sartorius, 2006). Health promotion then, can focus on how to improve an individual’s capacity to cope rather than solely on the eradication of illness, and support a practice shift where individual involvement in health achievement becomes the rule rather than the exception. Health, as a value, can garner greater importance now and in future, with health practitioners supported in their efforts to invest greater time with patients, gathering and applying social and mental health information (Bigham & Omole, 2021). Additionally, shared responsibility can be encouraged across sectors in the achievement of mutually agreed-upon goals related to health coordination, planning, and implementation and the improvement of policy and programs (Bradley et al., 2018; Brook, 2017; Government of Canada, n.d.; Huber, 2011; McCartney et al., 2019; Oleribe et al., 2018; Sartorius, 2006).
Despite a ground-breaking depiction in 1948, WHO’s definition does little to advance our understanding of health in 2022. It is evident that redefinition is needed in response to the changing systems, structures, research, and disease progression that influence how health is discussed, experienced, and treated in modern society (Bigham & Omole, 2021; Bradley et al., 2018; Brook, 2017; Huber, 2011; McCartney et al., 2019; Oleribe et al., 2018). Redefinition supports an improvement in the health field, bringing in a human element and encouraging an understanding of how a person feels relative to their disease, and not simply how they are progressing across a defined course (Bigham & Omole, 2021; Brook, 2017; Sartorius, 2006). Additionally, redefinition will promote buy in across sectors and collaboration between professions in support of continued research, improved measurement tools, responsive policy development, more equitable resource distribution, and greater patient involvement in health promotion and intervention (Bigham & Omole, 2021; Bradley et al., 2018; Brook, 2017; McCartney et al., 2019, Sartorius, 2006). While a perfect definition may be difficult to achieve, modern revisions are necessary if we are to take steps forward and address modern impacts on how health is understood, promoted, and improved.
References
Bradley, K. L., Goetz, T., & Viswanathan, S. (2018). Toward a Contemporary Definition of Health. Military Medicine, 183(suppl_3), 204–207. https://doi.org/10.1093/milmed/usy213
Bigham, B; Omole, M (2021, December 20). How social interventions can be powerful medicine (No. 12) [Audio podcast episode]. CMAJ Podcasts. Canadian Medical Association Journal.
Brook, R. H. (2017). Should the definition of health include a measure of tolerance? JAMA, 317(6), 585. https://doi.org/10.1001/jama.2016.14372
Government of Canada (n.d.). What is the population health approach? https://www.canada.ca/en/public-health/services/health-promotion/population-health/population-health-approach.html
Huber, M. (2011). Health: How should we define it? British Medical Journal, 343, (7817), 235-237. https://doi.org/10.1136/bmj.d4163
McCartney, G., Popham, F., McMaster, R., & Cumbers, A. (2019). Defining health and health inequalities. Public health, 172, 22-30. https://doi.org/10.1016/j.puhe.2019.03.023
Oleribe, O. O., Ukwedeh, O., Burstow, N. J., Gomaa, A. I., Sonderup, M. W., Cook, N., Waked, I., Spearman, W., & Taylor-Robinson, S. D. (2018). Health: redefined. The Pan African medical journal, 30, 292. https://doi.org/10.11604/pamj.2018.30.292.15436
Sartorius N. (2006). The meanings of health and its promotion. Croatian medical journal, 47(4), 662–664. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080455/pdf/CroatMedJ_47_0662.pdf
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