Monday, May 29, 2006
Teaser Appetizer: The Definition of Health
The world health organization (WHO) defines health as “A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” This definition entered the books between 1946 and 1948 and has remained unchanged.
Current medical knowledge is desperately struggling -- only with partial success --just to “merely” control “disease or infirmity.” while “complete well being” is unlikely to sprout out of our incomplete knowledge If your politicians were to legislate health by this definition, they will be in default for ever for one obvious reason: no nation – I repeat - no nation has the knowledge or the resources to deliver care to match this definition. We all learnt in the kinder garden – well except the politicians – not to promise what we can not fulfill.
This definition is a lofty, laudable visionary statement that may reflect a distant aspiration but its realization is elusive in current practice. In all humility, we should concede that “complete --- well being” is a probable unquantifiable metaphysical state which is unattainable without taming nature’s evolutionary laws of life and death. And to presume that we have the ability to do so is a whiff of arrogance – an aromatic trait our species emits in abundance.
The realization of this dream was probably considered feasible in 1948, when we had made a quantum leap in understanding infectious diseases and for the first time in human history, we were exuberant in our demonstrated ability to extend longevity by about twenty years in some countries But that was far before we could predict the explosion of health technology and understand its consequential individual, societal and economic effects.
Isn’t it time we seek a second opinion on the health of this definition and evolve a flexible definition which encompasses the current reality and is malleable enough to accommodate future developments?
While the WHO definition stays seemingly immutable, a new framework linked to human rights has evolved: The human right to health paradigm reiterates: the enjoyment of highest attainable standard of health is a fundamental right of every human being This linkage has provided an inspirational tool to demand “health..” The tenor of this discourse takes a cue from the rhetoric of Kofi Anan: “It is my aspiration that health will finally be seen not as a blessing to be wished for; but as a human right to be fought for."
This paradigm recognizes that violation of human rights has serious health consequences and promoting equitable health is a prerequisite to development of the society. The discourse rightly demands abolition of slavery, torture, abuse of children, harmful traditional practices and also seeks access to adequate health care without discrimination, safe drinking water and sanitation, safe work environment, equitable distribution of food, adequate housing, access to health information and gender sensitivity.
All nations are now signatories to at least one human rights treaty that includes health rights. One hundred and nine countries had guaranteed right to health in their constitutions by the year 2001 which qualifies it as an effective instrument for policy change; but it also raises some difficult questions.
Human rights discourse uses the words health and health care interchangeably. Rony Brauman, past president of Médecins Sans Frontières comments: “WHO's definition of a "right to health" is hopelessly ambiguous. I have never seen any real analysis of what is meant by the concept of "health" and "health for all," nor do I understand how anyone could seriously defend this notion.” The notion is more defensible if the demand of health care replaced the demand for health.
Yet no country in the world can afford to give all health care to all its citizens all the time. Nations conduct a triage of priorities according to their prejudices and large swaths of populations are not caught in the health care net. Even nations that have right to health embedded in the constitution face a gap between the aspirations and resources.
The human rights debate skirts round the issue by invoking the “Principle of progressive realization”, which allows resource strapped countries to promise increments in health care delivery in future This effectively gives a tool to the governments to ration and allocate resources, even if it conflicts with individual rights.
The following example illustrates the problem: post apartheid government of South Africa had enshrined the right to health in the constitution, yet the courts decided against a petitioner who demanded dialysis that he needed for chronic kidney failure. The court ruled that the government did not have an obligation to provide treatment. The court in essence transferred some responsibility to the individual.
Gandhi had also expressed his concern that rights without responsibility are a blunder. A responsibility paradigm could supplement the rights movement; a pound of responsibility could prove to be heavier than a ton of rights, but the current noise for rights has muzzled the speech for responsibility and “Complete health” is becoming an entitlement to be ensured by the state without demanding that the family and the individual be equal stake holders. Hippocrates said "a wise man ought to realize that health is his most valuable possession and learn to treat his illnesses by his own judgment"
This conflict will escalate further with the impact of biotechnology. A quote from Craig Venter gives the feel: “It will inevitably be revealed that there are strong genetic components associated with most aspects of what we attribute to human existence --- the danger rests with what we already know: that we are not all created equal. ---- revealing the genetic basis of personality and behavior will create societal conflicts.”
Derek Yach, a respected public health expert and professor at Yale University says “With advances in technology, particularly in the fields of imaging and genetic screening, we now recognize that almost all of the population either has an actual or potential predisposition to some future disease.”
We can’t help but rethink about health itself before we promise health care. An alternative definition can be derived from the health field concept of Marc Lalonde who was the health minister of Canada in1974. He surmised that interplay of four elements determined health, namely: genetic makeup, environment including social factors, individual behavior and organization of health care. The health field model holds many stake holders accountable.
Each stake holder approaches health with a seemingly different goal. (Even though they complement each other) A healthy person wishes not to fall sick; a sick person demands quick relief; a health care provider attempts to cure and prevent disease; a molecular biologist envisions control of molecular dysfunction; a public health person allocates resources to benefit maximum number of people; a health economist juggles finances within the budget; the government facilitates or hampers the delivery of care according to its priorities and the activist demands that every person has the right to the” Highest attainable standard of physical and mental health.”
Many stake holders mean more questions than answers. Who decides the limits of health a society should attain? Shall the boundary limit to basic primary care or extend to genetic manipulation to deliver well being? Who decides the mechanism of attaining that limit? Who decides positive mental well being? And who pays for it?
It is apparent that ‘Complete well being’ is as much an oxymoron as ‘airline food!’ We urgently need a new definition as a starting point for debate: a definition that is quantifiable for outcomes, accommodative of stake holders, absorbent of future advances, accountable for delivery of care and cognizant of limitations. The new definition has to be both correct and politically correct. Dr. Brundtland, former director-general of the WHO, wrote in the world health report that “The objective of good health is twofold – goodness and fairness; goodness being the best attainable average level; and fairness, the smallest feasible differences among individuals and groups.” We should match our expectations to reality.
These elements, compressed and enveloped into a workable statement, may sound as follows:
Health is a state of freedom from physical and mental consequences of molecular and psychological derangements caused by the interaction of individual biology and the environment; health care is an attempt to reverse such derangement by providing equitable access to all without discrimination within the constraints of available resources and knowledge.
You may call this, if you please: the 3QD definition of health -- you read it here first!
Posted by Shiban Ganju at 09:35 PM | Permalink
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