The main objective of the doctor’s work, in whatever field he or she functions, is ultimately the restoration and maintenance of health. Yet, as Smith pointed out some time ago, disease and health are ‘slippery concepts’ that we have not been able to define clearly hitherto.1 The difficulty of defining health was clearly illustrated when the distinguished figures of the World Health Organisation (WHO) were asked to undertake this task in 1948. Their response was that ‘health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’.2 Now, a definition should define clearly the nature of a subject as it is or by what effect it has; that is, what it does. In addition, in the fields of science and medicine, it should indicate how the subject is produced and enable it to be measured. The WHO definition did none of these things — it merely took one vague entity ‘health’ and defined it in terms of another equally obscure concept, ‘wellbeing’. It did, however, point out that there was more to health than simply the absence of disease, but this was not really a definition at all, being merely a rather vague description. The waters remained as muddy as ever and the measurement of health was in no way facilitated. Incidentally, the Oxford English Dictionary is no more precise on this subject. It offers a number of meanings including ‘soundness of body, that condition in which functions are duly discharged, spiritual, moral or mental soundness, salvation, well-being, safety and deliverance’ — all parts of the picture, but a real definition is still some way off.
I believe, however, that health can be defined, but for this to be done one has to view the doctor’s work from an entirely different perspective. The conventional view of most doctors has, for generations, been reflected by Smith’s interpretation of Sydenham’s philosophy1 on disease that it had an existence independent of the observer in nature and was ready to be ‘discovered’. In this context, the task of the doctor is primarily (and prior to the start of the 20th century was almost exclusively) the identification and management of disease presented to them by their patients. Of course there were pioneers like Edward Jenner and John Snow in the 18th and 19th centuries who drew attention to the importance of preventive measures and control of environmental forces. However, the profession was slow to learn from them and it was not until the 20th century that preventive care programmes focused on disease, accidents and a variety of other environmental factors likely to affect health. This form of prophylaxis has been developed very slowly and tends to be seen even today as a supplementary back-up service. Thus, disease is the main focus of the doctor’s work and the background to disease does not enjoy the same attention, which is why occupational health has only established itself very slowly across the last 50 years while the specialty of rehabilitation has an even shorter lifespan. By contrast, clinical care of diseases and accidents goes back thousands of years. So, I am suggesting that our failure to define health may well have been more influential in the evolution of our philosophy of medical care than, perhaps, we recognised in the past. Philosophers, who claim to be seeking ‘the ultimate nature of reality’, would no doubt point out to doctors that this is precisely what they are failing to do and that their patients are paying the price as a result.
Another side effect of the current view of health is that attempts have been made to classify medical disorders as diseases and ‘non-diseases’, although how one can identify the latter without defining the former is not explained.1,3 It is the failure to be clear in our minds as to what exactly we mean by health that leads us to explore cul-de-sacs of this type.
