OP-ED

Health Care for Dummies (and Innovators): In search of a practical definition of health

flying cadeuciiFor a while now, I’ve been working on an ebook about making digital health more useful and usable for older adults.

(Don’t hold your breath, I really have no idea when it will be done. I can only work on it for about an hour every weekday.)

In reflecting on the health innovation conferences and conversations in which I’ve participated these past few years, I found myself musing over the following two questions:

1. What is health?
2. What does it mean to help someone with their health?

Three Components

After all, whether you are a clinician, a health care expert, or a digital health entrepreneur, helping people with their health is the core mission. So one would think we’d be clear on what we’re talking about, when we use terms like health and health care.

But in fact, it’s not at all obvious. In practical parlance, we bandy around the terms health and health care as we refer to a wide array of things.

Actually defining health has, of course, been addressed by experts and committees. The World Health Organization’s definition is succinct, but hasn’t been updated since 1948:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

A more recent attempt to define health, described in this 2011 BMJ editorial, proposed health as “’the ability to adapt and self manage’ in the face of social, physical, and emotional challenges.”

This left me scratching my head a bit, since it sounded more like a definition of one’s resilience, or self-efficacy. Which intuitively seem much related to health (however we define it), but not quite the same thing.

I found myself itching for a definition of health that would help me frame what I perceive as the health – and life – challenges of my older patients.

Also, it seemed impossible to articulate how digital health tools might help us care for an aging population, if one didn’t start with a practical definition of health.

So after doing an hour of research in the literature (and finding endless scholarly rabbit holes), I ended up trying to sketch a model of health that felt true to my experiences.

In this post, I’d like to share what I came up with, and get your feedback. Then in a follow-up post, I’ll write about what this might mean for defining health care, and our efforts to improve or facilitate health care.

What is health?

Health is a dynamic state. For an individual, it involves three core components:

• How are you feeling? How do your body and mind feel? Are you experiencing any pain? Bothersome sensations? Mental distress? This component of health addresses the individual’s experience of suffering.

• How well are your body and mind outwardly working? Are your body and mind working as you expect them to, or need them to, or want them to? Can you get around physically as you usually do? Can you manage your thinking tasks? Can you see, hear, speak, and otherwise communicate effectively with others? This component addresses the individual’s ability to leverage body and mind in order to manage one’s usual activities and life tasks.

• How well are your body and mind internally working? This component relates to one’s inner physiology and function. When we peer inside, whether with modern technology, via the careful pulse auscultation used in some cultures, or any other method, is anything awry? Do we find signs of disease, disorder, or disruption? In Western medicine, we consider the workings of organs and cells, but other cultures have their own “inner workings” that they assess when evaluating health.

These three components are in constant interplay with each other. Right now I’ll refer to them your wellbeing, your macrofunction, and your microfunction. (But I’m not sure those are best terms.)

These three components of health are also in constant interplay with our social and physical environments, as well as with our nutrition and our “lifestyle choices.” For instance, rich social encounters and purposeful work improve wellbeing, as well as immune function and other aspects of our microfunction. Air pollution might make us cough, and can negatively impact our lung function, along with other less visible parts of our health.

Are these many external factors, and our behavior choices, synonymous with “your health”? I would call them influences on your health, or in certain cases “health care”, rather than your health itself. (And they aren’t diagrammed above, although I’d like to add them eventually.) These factors are incredibly important, but we confuse matters when we conflate things that influence health — such as access to clinicians, clean water, walkable cities — with the actual health of an individual.

Why does a person’s health matter?

Better health is an important end in of itself.

But to a large extent, health is a means to a more important end: that of living life.

In other words, being able to do the things we care about, need to do, and want to do. Being able to do things that give purpose, meaning, and pleasure to our lives. Being able to do the things that make us feel like our selves.

This is kind of obvious, but it’s actually fairly easy to lose sight of this when we get immersed in the weeds of health and health care. (Which is why the Unmentionables at Health 2.0 is so fantastic: it’s a much-needed reminder that health serves life.)

[Caveat: There is a lot of overlap between the life activities, but I haven’t yet figured out how to diagram this. Graphic design is not my forte.]

What is a health problem?

As a doctor, my job is to help people address their health problems. And I’d like for the digital health entrepreneurs to create tools that work better for this purpose.

So what is a health problem? How to define what people seem to need help with? How to define what digital health tools should help us – whether we are a patient, a clinician, or a family caregiver – address?

Here is a practical definition: a health problem is anything that is “wrong” with one or more of the three components of health above.

For instance:
• Wellbeing Problems: Examples include being in pain, being fatigued, having insomnia, feeling depressed, feeling anxious, feeling short of breath, and so forth. Many symptoms, pains, discomforts, and any other forms of suffering fall into this category.

Macrofunction Problems: These might include having difficulty walking due to arthritis, problems exercising due to shortness of breath, or problems thinking due to dementia. You could also include vision problems, hearing problems, and speech difficulties due to stroke. These issues often cause noticeable functional impairments.

Microfunction Problems: These would include problems such as having impaired glucose metabolism, high blood pressure, osteoporosis, kidney disease, as well as early stage cancer.

You’ll notice that problems with wellbeing and macrofunction are primarily person-defined. It’s the affected person – sometimes known as “the patient” – who experiences suffering, or difficulties in how the body and mind are working. Whereas microfunction problems are generally “expert-defined”: nobody knows they have osteoporosis until clinicians tell them.

Many diagnoses, diseases, or health stressors will cause problems in all three parts of health. For example, cancer symptoms and the related functional impairments (e.g. problems doing anything you can usually do) are the consequence of the cancer cells running amok within.

Congestive heart failure might cause uncomfortable dyspnea, as well decreased exercise tolerance, such that a person has difficulty managing usual ambulation and activities.

Your Life

Of course, there is a lot of room to argue about what constitutes “wrong” with a given health component. Cultural and social factors influence how people perceive their own suffering, or overt impairments. And we could quibble endlessly about what is ideal blood pressure, and how we might otherwise assess how right or wrong a person’s body and mind are internally working.

Still, in many cases, if most of agree that something seems “wrong” with a given component of health, this should provide us with a decent practical starting point for identifying health problems.

Do we need to distinguish between microfunction and macrofunction?

I believe we do. Problems with macrofunction are the things that people notice in themselves (or in others, when it comes to cognitive macrodysfunction). These are what patients are often most concerned about.

Macrofunction problems, along with forms of suffering, are also what directly impacts people’s ability to participate in life tasks, and their short-term quality of life.

So helping people correct, mitigate, or adapt to these types of functional impairments is incredibly powerful, if you want to address health problems in a way that makes people’s lives materially better. This is an approach that is common in geriatrics, palliative care, physical and occupational therapy, and behavioral therapy.

Microfunction, on the other hand, is what people need technical assistance to assess. (Historically that assistance have been clinicians, but we’re on the cusp of seeing advanced diagnostic tools in the hands of the public.)

Much of the work that we doctors do in modern medicine, especially in primary care, is address physiologic problems that are scarcely perceptible to the affected person: high blood pressure, high cholesterol, type 2 diabetes, kidney disease, asymptomatic atrial fibrillation.

We do this work because we are trying to prevent or delay more overt health problems, such as those associated with suffering and macrodysfunction. So it’s certainly worthwhile work. But it doesn’t always feel satisfying or worthwhile to patients, especially if they are pre-occupied by other problems which are causing suffering or overt functional impairments.

In fact, it seems to be fairly common that patients and clinicians are focused on different aspects of health. A typical example: a doctor might decide to unilaterally prioritize tinkering with the microfunction, such as by prescribing more statins, even though a patient’s most pressing concern is falls or pain.

Feedback? Suggestions?

All models are wrong and incomplete, but some are useful, as the saying goes.

Is this model of health and health problems useful?

What do you like, and what do you think I absolutely should change?

[Many thanks to Leslie Salmon-Zhu of GraphicRecorders.com, for drawing a preliminary version of Three Components of Your Health graphic.]

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Categories: OP-ED, THCB

26 replies »

  1. i am a high school student.in search of the definition of health i see this article. it is the nice one about health of a person.love it.thanks for your article.it helps me a lot.

  2. Thanks all for these comments, many interesting points to mull over

    Hmm. Well, I still think we need a practical definition of what we mean by health, especially when it comes to identifying problems that we’ll then try to help people with. Whether that help comes from clinicians, is paid for by insurance, or is facilitated by technology versus the clergy is another story.

    If I can ask about the conceptual model I described in the post, in which your health can be described as a combo of how you feel, how well body and mind are obviously functioning, and how well body and mind are microscopically functioning.

    Any objections, and if so what change do you suggest? I still feel this model maps on pretty well to how I assess a person’s health and health problems, and to how we try to help them.

  3. I find I’m “healthy” until I go to an MD for a physical. They seem to find all sorts of billable “health” problems that I was unaware of. That makes me feel un-healthy paying for the deductibles.

    I’ve stayed healthy not going to doctors, and hospitals are just an expensive way to die.

  4. Our chieftains and medicine men (and women) would be well served to help us understand how to live within the balance of nature that we have inherited. I believe the term is called homeostasis. Altering altering our nature will send us in the trajectory overtime of the great unknown… Happy Thanksgiving to all!

  5. I agree, in the end the pursuit of population health may be the ultimate paradox, because the unintended consequences of changing environment, genetics and behavior alter the balance of our nature. Engineering our environment by adding more efficiency and convenience changes thousands of years of evolutionary traits. Altering genetics or scripting behavior for more optimized performance changes the self cleansing system of nature. All, a bit like the sorcerers apprentice in Fantasia. But alas
    , “you can’t go against nature because that’s nature too.”

  6. Health, like happiness and free will, is largely a metaphysical construct. Any attempt to objectify health is likely to be partially successful but too grave a simplification to link that metric with the performance of a healthcare machinery.

    The metaphysical health of a nation is better handled by clergymen than physicians.

  7. Being optimized or healthy becomes more important when the organism gains awareness of self and tries to measure and game its success. Otherwise the survival dance plays itself out in an ongoing pattern based on environment, behavior, genetics and other limiting factors.

  8. I would say health is a collective snapshot at any given point of many different factors that contribute to the organisms survival for the moment and perhaps over time. Whether it is always optimized may or may not be important depending on other factors that interact with the organism at particular moment or over time.

  9. @Doug

    I guess you are saying that health = Darwinian success. But a woman could have 8 kids and then die at 45. Each kid survives and becomes a writer for THCB. Was she healthy?

    This is central to the antagonistic pleiotropy hypothesis, first developed by G. C. Williams in 1957.[5] Williams suggested that some genes responsible for increased fitness in the younger, fertile organism contribute to decreased fitness later in life. An example is the p53 gene, which suppresses cancer, but also suppresses stem cells, which replenish worn-out tissue.[6]

  10. Health is an awareness of organisms that have organized beyond basic survival to understand that behavior, environment and genetics have impact.
    Where the individual organism and/or the collective are trying to enhance thier ability to survive, reproduce and take over thier environment. Healthcare is the practice of organisms to enhance thier performance in order to survive, reproduce and take over thier environment. Environment, evolution predators and other limiting factors are the counter balance in this ongoing drama.

  11. Maybe health is the degree your life–body, intellect, mental health, personal and civic achievement, kindness, altruism, etc.–aligns with its potential?

    “Population Health” is even more abstract. What could it mean and why are policy people using this phrase?

  12. Clinical options to achieve a clinical effect

    Prescribe yes
    Prescribe no
    Prescribe more
    Prescribe less
    Prescribe different
    Combine
    Change Duration
    Change Schedule
    Change Type of administration
    Control administration
    Combine/change any of the above

    External Considerations

    Financial Considerations
    Complimentary or Alternative Therapies in conjunction or apart
    Complimentary, Alternative Behaviors in conjunction or apart
    Supportive Diagnostic & Measuring, Management Tools/support/management
    Demographic, environmental factors genetic factors, behavioral factors, mental/aptitude, Motivation, condition type/state comorbity
    Allergies

    Potential Outcomes

    Cure, Efficacious Response, Control/Manage/Prolong, Comfort, No Effect, Adverse Effect, Death

    Society Rationale/Expected Outcomes

    Productivity, Quality of Life, Control Costs, Extend Life, Provide Comfort, Retain, Moral Duty, Human Right

    Bench Marks: Life Expectancy Productivity, Absenteeism, Retention, patient satisfaction…type of response

    Individual Rationale/Expected Outcomes

    Survival, Quality of Life, Maintain, Prolong Life, Comfort, Duty, Right, Abuse

  13. Leslie, health is not just pretty broad, it’s very broad and a physician only affects a tiny portion of the individual’s world of health. Everything affects the health of an individual and one probably could say that sanitation has done more for the health of the individual than medical care.

    I think we can safely say that a physician should only act when as an observer there is something the physician can do to improve the patient’s functions and permit the patient to fulfill his purpose. That makes this tiny portion of healthcare very variable from patient to patient and requires the physician to actually know his patient.

    We have taken that word health and created a new entity out of it that no two people will ever completely agree upon. Today we think of healthcare as those things covered by insurance or that require a licensed ‘healthcare professional’ to take care of. That IMO is hog wash.

    The treatments provided by physicians are based upon what the observing physician recognizes relative to the individual’s purposes and functions. Thus you as a physician will not get too crazy if your neighbor injures his fifth finger. It will heal and if a tiny bit of function is lost it will never be noticed. But, if the purpose of that finger was to to play the piano at Carnegie Hall one might have a different approach. That finger might not function well enough.

  14. Sounds reasonable. It’s pretty broad though. My main concern about this definition is that I would have trouble using it to assess a patient, and figure out how I was going to help.

    Good point re the role of the observer. Do you think we should be encouraging people to take a more active role in observing and assessing their own health?

  15. I like the way you are breaking things down. Why don’t we talk more about the different types of tools we use to influence health?

    It might help we described pharmaceutical health tools, DME health tools, counseling health tools, etc. And yes, I would add digital health tools. (Or what should we call the innovations on display at Health 2.0?)

  16. Thanks for this comment, lots to think about here.

    I think there’s a difference between defining what is healthy, and trying to break down what do we mean when we talk about health, and health problems.

    I also think doctors need a way to think about a person’s health problems, before deciding which part is suited to their doctorly capabilities. What if you are socializing less because of your severe knee pain? We aren’t going to arrange friend dates but we could help treat your pain, or arrange for assistive devices that improve mobility.

    In general, I think it makes more sense for clinicians to try help people feel (and be) healthier, rather than “healthy” which is some state that most of us can’t entirely acheive even if we do define it.

  17. I think those are indeed very important questions and I wish we asked them more often.

    Well, the average patient I used to see in primary care was not bothered by many of the things that we were fussing about (Hgb A1c of 8, creatinine of 2, etc). This is part of why I’ve been trying to figure out a way to describe health that encompasses these different angles.

    thanks for the thought.

  18. Thanks for commenting, I appreciate it.

    Hm. So if your concerned spouse asks me “How’s William’s health?” (and you’ve given me permission to talk to her about your health), I should talk about your epigenetic damage?

  19. This is the way I look at it.

    Health is a non judgmental term describing how an organism functions within its environment. The terms good and bad are artificially ascribed to the organism based upon the observer and what he is observing in relationship to the organism’s ascribed purposes and functions.

  20. Many interesting points, but how about dropping the jargony phrase “digital health”?

    If digital health refers to using digital tools to improve our health, we also have pharmaceutical health, and durable medical equipment health, and counseling health, and surgical health, and on and on . . .

  21. The biggest problem I see is that you use the word “work” as in “does it work?” in the definition. What does it mean for your body to work for you? Most definitions of health never really define what healthy would be, they just assume it as a given, which basic begs the question (“what is health?”)

    I think a good starting point to is to just punt on the health question and focus on defining medicine. Doctors fix medical problems, not health problems in general. M.D.s (note the M) can’t fix lot of health problems and lots of things that fall under the big umbrella of health (do you have friends? are you depressed?) are better handled by non-medical experts. You shouldn’t go to a hospital to make friends, yet at the same time there’s no denying that if you have zero friends you have a social/well-being problem which everyone seems to agree is a health problem.

  22. The risk of walking into a healthcare facility is huge compared to the benifit.

    No one should ever do that without a specific question that is important to them

    Health should be private. It does not need to be in a database to exist.

    Do not terrorize people with fear mongering. Their mental health will be harmed.

  23. Is anything bothering you?
    Is there somethng you wish worked better?

    This isn’t complicated.

    We often don’t have great answers to those questions. But we should do the best we can.

  24. A good start, Leslie. I would like to see everyone get a full genome and proteome workup and look at epigenetic damage. Also keep researching environmental brain-damage markers, like effects from divorce. Then, in a couple of centuries, we will be able to remove methyl groups from our DNA and histones, add new synapses, and reduce our entropy a bit and feel younger and younger. The goal should be to feel really good and be able to help others and have fun: helicopter ski and surf and make love for a century. :-), yet retain our wisdom and friendships and do good mathematics and music, and run great businesses. IOW be in heaven on earth.

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