As The World Changes, Health Is Defined the Same

Credit: Unsplash / Miguel A Amutio

Engraved into a wall on a campus building at Harvard T.H. Chan School of Public Health is the World Health Organization (WHO) definition of health.

Melinda Buntin, PhD, would pass this engraving every day on her way to her graduate courses. Years later, she recites the 21-word definition, verbatim, in an interview with HCPLive—not missing a beat nor word: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”¹

What strikes Buntin, currently the chair of the department of health policy at Vanderbilt University School of Medicine, peculiar about this definition in 2023 is the modernity; it may as well have been written for today’s generation, let alone the one she knew as a young student.

In reality, that definition is 75 years old as of today. Friday marks the anniversary of the adoption of the WHO constitution during the first World Health Assembly on April 7, 1948—a holiday now recognized annually as World Health Day.²

It may come as a surprise to some that health policy experts and legislators operate with the same definition of health today as their predecessors did in the short aftermath of the last world war—a definition which, to Buntin’s credit, holds up impressively well in 2023. But the reality is that this definition is still only an ambition, not an accomplished and reinforced standard, for health among a global population that faces many more challenges to its wellbeing than it had only 75 years ago.

“There are so few things in health care that hold up that well, and I think it really has held out well as an aspirational goal,” Buntin said. “But I do think that 75 years later, think about it as an aspirational goal, because we still struggle to assure people access to basic physical health care, much less mental or social wellbeing.”

On this World Health Day, HCPLive asked experts including Buntin to consider whether the common standards for health hold up today—and what more is needed to finally achieve the WHO’s goal.

Today’s Challenges to Health

The WHO’s definition and standards for health were inspired by what Dr. Ruediger Krech would describe as an “interesting time” in global history: the short years proceeding World War II, a period of understated turmoil and distress across many factions of the globe. International agencies like the United Nations (UN) were established in both a theoretical and practical effort to improve collaboration among world powers; on the heels of a global catastrophe that cost up to 60 million lives and did irreparable damage to perhaps just as many, there was sentiment that an international health agency could emulate the UN’s reach.

But it was also a time of advancing epidemiological research—some of it borne from the tracing of communicable disease among World War II soldiers. Policy makers were increasingly wary of the risk of outbreaks across borders, perhaps likening its global impact to the harm a world war could bring. That is how the very modern definition of health was written 75 years ago.

“When there’s devastation in a whole continent, that has consequences for the whole world,” Krech, director of health promotion at WHO, told HCPLive. “So they looked at health not merely as the absence of disease, but the complete state of social and emotional wellbeing. And when you look at that, you think, ‘That’s very visionary.’”

Perhaps why the old definition resonates so strongly with experts like Krech and Buntin today is that global dispositions in 2023 unfortunately resemble those seen in 1948. The COVID-19 pandemic has sent international public health strategy into disarray; consequences of climate change have come into full view as environments and regions are burdened by health-related challenges; and only last year the Russo-Ukrainian War marked the return of political conflict to Europe.

Krech even points to issues around mental health and wellbeing during the digital age—a global issue that may warrant greater concern in different circumstances.

“There’s just so many crises,” Krech said. In a 30-minute conversation, he manages to review at least another half-dozen challenges to the goal of optimal global health, including:

Inequity

“There’s quite a few people who are very conscious of their health—who actually do much more for themselves,” Krech said. “They actually have a healthy nutrition, they don’t drink too much, they don’t smoke, they are very health conscious. And that is a growing number of people, especially in affluent societies.”

In the same societies, however, there are increasing rates of people with decreasing access to healthy foods and are in unhealthier environments at both work and in general. They may be struggling to afford costlier healthy living, Krech said, facing what he calls an “upstream of conditions” that challenge the opportunity for an overall healthy status.

Stress and anxiety

Much research has defined the link between the COVID-19 pandemic and increasing global adult anxiety—some has even positively correlated global stress rates with the infection rate of the virus.³ This would generally be a more feasible stressor to overcome, Krech said, be it not for the burden of a multitude of other global and national crises afflicting people the same time as the pandemic.

“Many people are extremely stressed, because their ability to understand what’s going on, how to take all this information of these different crises, then how they therefore make decisions for their own behavior and their own is all compromise,” Krech said. “Our ability to take control over our health and lives is compromised.”

There’s also a greater sense of global insecurity than anything previously observed, Krech said—uncertainty over what may happen in 2 years, let alone 2 months.

Chronic disease

Approximately 3 in 5 US adults currently have a chronic disease per the Centers for Disease Control and Prevention (CDC); another 2 in 5 have multiple chronic conditions.⁴ The global burden of chronic diseases—whether they be cancer, cardiovascular or cardiometabolic, pulmonary, immunologic, or otherwise—is increasing annually to an extent at which it should be deemed its own pandemic, Krech said.

About 65% of all chronic diseases can be prevented, Krech said, with clear behavioral risk factors including tobacco and alcohol use, unhealthy nutrition, exercise neglect and pollution exposure being targets for intervention among experts at agencies including WHO and the CDC. Each of these risk factors warrant some extent of alteration as to how they are regulated or exposed to higher-risk populations, Krech argued.

He pointed out the hypocrisy of free markets allowing for increasing profits for each of fast food, tobacco, and alcohol industries—while hospitals and health systems on a fixed rate of funding are overwhelmed by an aging patient population incurring disease from years of unhealthy substance use and poor diet.

“This is everything but market economy, that we’re actually subsidizing these unhealthy products,” Krech said. “We need to get real and on the contrary, use financial measures in order to create healthier lives.”

With the advent of so many health crises, though, comes the capability to define emerging threats earlier and apply an understanding of clinical impact into public health decision-making. Krech stressed that bolstered, real-time data collection and refined avenues of cross-care communication has granted clinicians more ability to shape policies that impact health.

“We have instruments at hand today that are able to assess implications of policies, and that is important that we offer this to those decision makers so they make more informed decisions,” Krech said. “I think it’s really quite important that we’re more outspoken about this as medical professionals—about what we see happening in daily practice, but also we use the instruments at hand that decision makers don’t say 10 years later, ‘Had we known what health implications that had, we would have decided differently’.”

Of course, that capability raises the question of who truly dictates optimal health, and what is the role of each stakeholder?

The Stakeholders of Health

The WHO’s primary definition of health is embedded among a 9-item constitution that the organization first ratified in 1948. Among the core concepts of the constitution are these statements:

• The enjoyment of the highest attainable standard of health is a fundamental human right.
• Healthy development of children is a basic importance.
• The informed opinion and active cooperation of the public is critical in improving a population’s health.
• Governments have a responsibility for the health of their people.¹

These statements speak very directly to the rights of people in receiving and being involved with the decision-making toward optimal health, as well as the liability of legislators in providing such rights. There is not one mention of the roles or responsibilities of caregivers, health experts, or otherwise agencies.

A fair rationale for this exclusion is that it is ultimately the individual who dictates their health goals—a notion emphasized by Anand Parekh, MD, MPH, chief medical advisor of the Bipartisan Policy Center. In an interview with HCPLive, Parekh described the role of health care professionals as facilitators toward those individual health goals, and experts on the subject of quality-of-life and longevity as they relate toward health.

Unfortunately, this dynamic that puts greater responsibility on the individuals and their representative government could lead to a situation such as that in the US—where little emphasis is put on preventive care.

“As a society, we would rather wait for an illness, prior to seeking disease prevention and health promotion guidance,” Parekh wrote in an email. “Many experts have called our health care system a ‘sick care’ system.”

Echoing the sentiments of Krech, Parekh mentioned the impact of poor nutrition, exercise neglect, substance abuse and poor mental health as clear drivers of preventable chronic disease. But policymakers frequently operate in a reactive, not proactive mindset; while the clinician seeks to mitigate risks, the legislator has no such priority.

“Prevention requires patience—there are few ‘quick’ wins and when wins materialize, they are often invisible (ie., ‘We’ve averted something’),” Parekh wrote. “Policymaker education is necessary to counter ‘nanny state’ arguments. It is not easy to make money from prevention in a ‘sick care’ system, though payment incentives are slowly changing.”

There’s also clear dissonance between how clinicians and individuals prioritize health. American College of Presidents (ACP) president Ryan D. Mire, MD, told HCPLive that the greatest differentiator in a physician’s and a patient’s perception of health is simply subjective opinion: A patient may interpret health strictly on how they feel, whereas a clinician is reliant on vital signs, test results and examinations to determine their health status. Uncontrolled chronic conditions without clear symptoms, such as hypertension, may burden an individual who has defined themselves as healthy—thereby again limiting the opportunity to prevent disease.

That is not to say, however, that Mire and colleagues subscribe to the notion that health is strictly a disease-free status. “In order to acquire a more comprehensive health assessment, it requires an individualized approach to each patient,” he told HCPLive. A clinician’s promotion and guidance of healthy living standards, therefore, may be the best thing they could provide the individual pursuing optimal health.

Unfortunately, health-related policies and government spending in countries like the US are still behind on this pursuit.

“Of the $4 trillion annual US health spend, only 3% is devoted to public health, 5% to clinical preventive services, and 6-7% to primary care (and these categories are not mutually exclusive, so overlapping),” Parekh wrote. “Ultimately, our spending reflects our priorities, and our priorities reflect our values. The question for us is—how healthy of a country do we aspire to be?”

The Never-ending Goal

Since Buntin first memorized the WHO’s definition on the walls of her graduate school campus between classes, US health policies and their targeted goals have evolved greatly. When Buntin is speaking to HCPLive this April, she is preparing a final exam for a health economics course at Vanderbilt. Compared to even a decade ago, the course syllabus is laden with a great deal of discussion and research around health equity. There’s also more emphasis on COVID-19-emergent topics like vaccination strategies and social distancing, and the limitations of health insurance in 2023 with regard to accessible care.

“So I do think that we have a broader conception of health and how to achieve it than we did when I first graduated school—or even 10 years ago,” she said.

The definition of health has never changed partly because it has never been absolutely achieved, let alone exceeded; what the WHO defined 75 years ago remains an optimal target for every individual, clinician, policymaker, and otherwise stakeholder in health strategies. But it may never actually be achieved, because the perception of health is shaped by a population—a population that which, over generations of time, may uncover new understanding and standards for wellbeing, longevity, quality-of-life and other parameters of health.

Buntin sees significant movement in the last 10 years to counteract the greatest modern challenges to the population’s health: record-low uninsured rates in the US, greater investment in chronic disease management and intervention, increased access to health care for hard-to-reach populations, and a refined standard for health intervention outcomes. But while these strategies contribute toward more improved-health opportunities in individuals, she doesn’t believe it’s enough for the population to reach the aspired goal of optimal health.

It may have been a fact retroactively learned, but the WHO’s definition of health may not be achievable. In fact, in 75 years, it never has been. What constitutes one’s health is a combination of factors—both positive and negative, some controlled and others self-determined—and the current knowledge that determine each of those factors’ roles in health.

The work is never done—nor is it meant to be. Since 1948, the definition has been perfectly under pursuit.

“I would not presume to alter a definition that has held up so well for 75 years,” Buntin said. “At the same time, I would challenge us to find a person on the planet who would call themselves ‘in a state of complete physical, mental and social well-being’.”

References

1. ^{World Health Organization. Constitution. Accessed April 7, 2023. https://www.who.int/about/governance/constitution}
2. ^{News release. World Health Organization. World Health Day 2023: Health For All. Accessed April 7, 2023. https://www.who.int/news-room/events/detail/2023/04/07/default-calendar/world-health-day-2023-health-for-all}
3. ^{Daniali H, Martinussen M, Flaten MA. A global meta-analysis of depression, anxiety, and stress before and during COVID-19. Health Psychol. 2023;42(2):124-138. doi:10.1037/hea0001259}
4. ^{Centers for Disease Control and Prevention. About Chronic Diseases. Accessed April 7, 2023. https://www.cdc.gov/chronicdisease/about/index.htm}