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 –
- Adapt
- Create
- Engage
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.
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Bob,
That first chapter in A Thousand Plateaus by Deluze and Guattari made much sense to me too. It’s a celebration of individuality, or what Stanley Keleman (http://www.centerpress.com), calls a personal world.
However, Deluze and Guattari are for the most part beyond my comprehension. How to make yourself a body without organs remains opaque to me.
But the rhizome is an apt metaphor for small businesses. They constantly adapt, grow, and die. Then something else bursts into being. The rhizome is a metaphor for the creative process. As everything changes all the time, stability is process. What we call failure is a necessary part of the adaptation process. I feel lucky that I went to art school (in the UK). At that time, our individuality was encouraged. This is not the case for most.
Adaptation is improvisational. Two weeks ago, I was at a somatic workshop with Stanley Keleman in Berkeley. The work was about a formative approach to making memories. As I understand it —and I only have a partial understanding— memories are anatomical structures that are inherited. But we have the ability to work with them through Voluntary Muscular Cortical Effort. This formative approach doesn’t lend itself to a simple explanation. However, you might be interested in reading Keleman’s book, Myth & the Body with Joseph Campbell.
I found it gratifying that this somatic work has no failure quotient. We are learning to be our differentiated selves, not a societal model. How close to that is the artistic way of being in the world!
In order to create we have to invoke a play response. Think about writing. I start by just making a mess. I get words on paper. I play around with it until something emerges. I often don’t know where I am going. This ability to play and be open to experience is what I would consider one vector of health. And what is the relationship between humor and health?
I was surprised that your medical literature does not have a definition of health. I think it was before Maslow that all psychotherapy was aimed at maladjustment or disease. Back then it wasn’t about living life as a human could.
Adam Phillips, in his book, Going Sane said there is no definition for sanity. So sanity and health are hard to define. It’s a bit like the obscenity trials in the late 1960’s. No one could define what obscene was but they knew it when they saw it.
Thank you Christopher – what a lot of interesting and thought provoking points!
I confess that I don’t find Deleuze easy either but how I’ve kind of made his thinking work for me is seeing how it has informed (or at least is consistent with) the fairly new scientific paradigm of the Complex Adaptive System (CAS). The rhizome certainly fits as a model for a CAS and some of Deleuze’s other important concepts such as his focus on becoming not being and the giving of importance to the connections between things rather than the things in themselves – oops! Does that make sense? So, yes, I still have figured the body without organs bit – but I haven’t given up!
I certainly do think that constant change, networks, non-linearity and the importance of understanding difference really do help us to understand both health and disease.
The thing about health not being defined in medical literature is certainly surprising but a friend said to me that apparently if you look at standard textbooks of Biology you won’t find index entries for “life”!
It’s true that sanity is no easier to define than health, but sometimes it seems the most important things in life are not easily definable!
Thanks for the book recommendation. I’ll chase that up.
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I agree that the whole issue of health (and illness) is problematic or perhaps I should say perspectival. Still, we can conceive of God as having a final, objective word on that, even if we can’t.
As for your definition, I think it’s a good one. But on point three* I hesitate a bit at the word “interaction.” If this includes saintly intercession, then okay. If it doesn’t then I think it could be improved upon. Along these lines, we have to consider solitaires like Emily Dickinson. Were they unhealthy? She herself wrote on this point re mental health and illness.
MUCH madness is divinest sense
To a discerning eye;
Much sense the starkest madness.
‘T is the majority
In this, as all, prevails.
Assent, and you are sane;
Demur,-you’re straightway dangerous,
And handled with a chain.
(Emily Dickinson, The Complete Poems of Emily Dickinson, Part 1: Life (11), Boston: Little, Brown, 1924; Bartleby.com, 2000. http://www.bartleby.com/113/)
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*3. continuing interaction with others and with the environment, building connections, points of contact, loving and being loved, in short, engage.
hey thankyou ep for this very thoughtful contribution
Maybe I should be clearer about my use of the word “interaction” – I mean that every creature is embedded in the environments in which it exists – physical, social, cultural environments and so on – I guess what I’m thinking about is when the flows in and out between the environments and the individual are blocked or disrupted ill health often follows. There’s nothing wrong with solitude but if you aren’t eating, drinking, breathing, living…..then it’s not healthy! The question for me is more whether or not an individual’s life style is enhancing their quality of life or not – are they, on their terms, leading a GOOD life, and are they growing or not?
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I wonder if the notion of allostasis and allostatic load may be sufficient as explanations without having recourse to Deleuze (a thinker whose work is impenetrable to many, myself included). Allostasis offers a plausible explanation as to why addressing a symptom with the blunt impact of a drug might be insufficient in the absence of lifestyle changes that had contributed to the manifestation of that symptom.
I liked several examples of allostasis and allostatic load there were discussed in this item about Allostastasis and Happiness.
Thank you for this.
I think the concept of allostatic load is a very useful one. I completely agree. Thanks for the link also.
My Deleuze references are just to a framework of understanding that makes sense to me – I totally agree that his writing is very difficult but I’ve read quite a number of more easily readable authors both from a philosophical and a scientific perspective who have made his concepts more clear to me. I do think a lot of his concepts are highly relevant to a complexity science view of life.
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Really interesting post. I think I was struck by the interrelation between physical and mental health. I’m possibly on the less erudite scale but I can definitely relate to the idea of positive health promotion rather than the constant focus on illness as a part of a medical model.
I expect that the Adapt, Create, Engage model can be used on many different levels and is meant to be interpreted as such.
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I love this. ACE. 🙂
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Very nice information.
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I suspect that the focus on what’s *wrong* with the body in terms of foreign beings stems from a desire to be right. It’s much easier to focus on an external influence that behaves in a simple way than trying to understand the bigger picture of an individual. I find this is doubly true when you try to engage a person’s attitude. There is a focus in the uk school systems that getting thigns right is the ultimate goal, and getting it wrong should be avoided at all costs. As such I’ve found people can be *incredibly* defensive about things that they feel are right even if it appears that attitude (or lifestyle choice etc) doesn’t serve them.
Your point about adapting (and someone elses about improvising) is indicative of a willingness to be wrong, and to experiment, and therefore learn.
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