This is the very first question I ask students of life cycle nutrition to answer before we begin to study the physiology and pathophysiology of preconception, the prelude to the life course. Common student responses to this question include health as optimal physiological function; the absence of disease; integration of mind, body, and spirit; or psychospiritual acceptance of one's condition regardless of physiological status. How we answer the question, “what is health?” reveals much about the underlying preconceived notions we have about the body and human flourishing. Furthermore, the answer reveals much about how we see ourselves in relationship to one another and the wider world.
The word health itself hearkens back to Proto-Germanic and Old English terms that refer to wholeness, soundness, and holiness. In Middle English, the evolved term helthe referred to physical wellness as well as prosperity, happiness, welfare, and safety. If the word health is etymologically Indo-European, its formation has been paradigmatically Greco-Roman. Ancient philosophers as old as Hippocrates developed a model which persisted for over 1,000 years as the prevailing paradigm of medicine: the humoral model. It espoused the idea that each individual is comprised of four elements, which, when in balance, results in health. An imbalance of these humors results in illness of body, thought, or affect.
Documents and art from the Middle Ages reveal that this humoral model was especially popular in that era. In her essay “Hildegard of Bingen and the Greening of Medieval Medicine,” Victoria Sweet highlights Hildegard’s pioneering adaptation of the 4-humor model to her sociocultural context and her indigenous German form of medicine as “a praxis that both reflects and expresses the premodern relationship of humans with the natural world." Hildegard's work is unique in its tendency to associate theological matters directly with human health and disease and offer botanical and natural remedies for spiritual and physical ailments.
Several centuries later, the 4-humor model remained the prevailing paradigm for medicine. In the 16th and 17th centuries, two formidable philosophers and natural scientists, Francis Bacon and René Descartes, altered medicine's fate. Bacon formulated an empirical method for testing knowledge by attempting to disprove a hypothesis. For example, he argued that scientists should repeatedly experiment on human subjects to observe whether external factors caused illness. Bacon’s ideas were accepted over time and led to the establishment of the Royal Society (widely believed to be the first scientific journal) and, for better or worse, initiated the commercialization of science and medicine.
The wide adoption of these ideas, dubbed the "Baconian Project" by bioethicist Gerald McKenney, led to the adoption of a cultural imperative: that humans can and should aspire to eliminate suffering and expand human volition. In his essay “Bioethics, the Body, and the Legacy of Bacon,” McKenny notes that the modern "obsession with bodily perfection" (i.e., health) through the eradication of imperfection and suffering has become the banner of modern medicine. This obsession was enabled and promulgated concomitantly with modern technology. As a result, technology and medicine have been elevated and lauded for their unsurpassed potential (if not actual ability) to end suffering. Societal adoption of this concept promoted by Bacon and Descartes and carried on by many others, has engendered a society defined by self-determination, essentialization of the body, and instrumentalization of nature to fulfill the new human moral project to eradicate suffering at all costs. Perhaps most problematically, medicine has become the ultimate hope for the salvation of a society in denial about its susceptibility to suffering. This has resulted in the idea that modern healthcare is a market enterprise in the business of "fixing" disease rather than promoting health. McKenney laments modern bioethics' complicity in this scheme because it has not pressed medicine on these issues. He suggests that it is precisely the role of bioethics to ask tough moral questions of medicine and medical technology.
Why has our society failed so miserably to promote health even as advances in technology and medicine have brought about a dramatic increase in human life expectancy?
The 20th century was defined by rapid advances in technology, eradicating or preventing many infectious diseases, and dramatic increases in human life expectancy. Yet the Baconian project persists, and the transition from 20th to 21st-century healthcare has made clear the error of this framework. During the past year, as the globe has grappled with COVID-19, the stark reality is that an individual’s autonomy (e.g., choosing not to wear a mask) is not necessarily the highest good. Furthermore, the eradication of suffering is an impossible global project. In addition to battling an acute infectious disease, we are battling a decades-in-the-making chronic disease epidemic. Those at the highest risk for severe COVID-19 outcomes are precisely those groups at the highest risk of chronic disease. Why has our society failed so miserably to promote health even as advances in technology and medicine have brought about a dramatic increase in human life expectancy? The trajectory of medicine and healthcare have always followed in the footsteps of shifts in culture and technology from Bingen to Bacon. And here we are again, at the precipice of a new kind of medicine made possible by the sequencing of the human genome not twenty years ago.
Our definition of health can and should adapt to the changing times; however, societies should not lose sight of the purpose of health–human flourishing. Current uses of the term health vary. Dictionary definitions include “the condition of being sound in body, mind, or spirit, especially freedom from physical disease or pain." 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.” [1] These definitions indicate an emergent trend in thinking about health beyond the body, indicating an emphasis on psychosocial-spiritual wellbeing or “wholeness.” The WHO goes so far as to say that health is the attainment of complete wellbeing across multiple factors, a proposition challenged by the scientific community tasked with objectively measuring health sense and others who consider the WHOs definition unrealistic. In response, other frameworks have emerged, such as the Wellness Wheel (and its variations), which typically outlines eight to ten dimensions of health. In this model, an imbalance among the dimensions causes a diminishment of wellbeing and potential distress.
We can immediately see how even this paradigm is inherently problematic for those who are aging, those who live with a disability, or those who are otherwise not considered physically or physiologically normative
Unfortunately, a paradigm based on a relative balance of life's myriad facets is immediately problematic (and suspiciously humoral). Anyone who scores “low” in one area or another is deemed “imbalanced.” We can immediately see how even this paradigm is inherently problematic for those who are aging, those who live with a disability, or those who are otherwise not considered physically or physiologically normative despite the individual’s overall wellbeing and self-efficacy. The ghost of Bacon persists. Our modern definitions of health have failed to account for diversity in what it means for humans to flourish. Instead, health has become standardized by Western norms derived from millennia-old conceptions of bodily perfection and individual autonomy. Above all, we value the manifest destiny of beating the odds in a society that considers death the ultimate failure. Yet the odds will never be in our favor; we will all face death one day. If health is defined by the eradication of suffering and the perfection of the body, no one will ever be healthy (although there are certainly those who would dispute this claim).
Nevertheless, the notion that health is the highest good remains with us. McKenny called out the modern obsession with bodily perfection and its Victorian antecedents, which required an “almost continuous monitoring of one’s body.” We are faced with a moment in human history where the ability to monitor even the minuscule movement of molecules within us has become possible through continuous glucose monitors; in-home lab tests; genetic and genomic tests; wearables that measure rest, sleep, and activity; food trackers; mood trackers; stress trackers; oxygen saturation monitors and the like. We are monitoring ourselves like never before. Of course, many benefit from this type of monitoring, especially those with conditions defined by swift alterations in life-sustaining functions. What about those who have a relative tendency toward allostasis? If one typically responds well to physiologic and psychosocial stressors, is continuous monitoring helpful or harmful? Do they lead to meaningful behavior change and ultimate, improved health outcomes? What of those who cannot afford such tools, but are pressured to adopt them? Are we facing the evolution of the bioethical problem that McKenney draws out: that “bioethics is silent on the most urgent moral questions raised by the technological transformation of medicine” due to its complicity in this Baconian ideal of eliminating suffering and elevating human autonomy? Is this health?
A shared meaning of health has eluded us. There seem to be as many definitions as cultures, health organizations, political and economic agendas, and maybe even human beings. As many critics of modern medicine have facetiously observed, healthcare deals with disease, not health. Modern ideas of health are completely oriented to the self in isolation. Yet, the long arc of human history should remind us that physical, emotional, spiritual, mental, social, and other facets of health are inextricable. Ancient paradigms such as Traditional Chinese Medicine, Ayurveda, and Native American Medicine do not fragment the being so neatly into planes of existence like the Hellenistic mind-body dualism that has become so embedded within our collective psyche. A holistic sense of self in context cultivates a more robust notion of health and human flourishing.
A definition of health as community, society, and ecosystem provides a thicker sense of the term. Wendell Berry criticizes the modern view of health as reductive and “almost fanatically individualistic…” insisting that health “is at once wholeness, and a kind of unconsciousness” (Berry 1994, 1-2). We must seek to integrate, not just balance, the many facets of our lives. He takes the word health back to its roots: heal, whole, and holy. Berry goes on:
…healers are properly obliged to acknowledge and respect the holiness embodied in all creatures, or that our healing involves the preservation in us of the spirit and the breath of God. If we were lucky enough as children to be surrounded by grown-ups who loved us, then our sense of wholeness is not just the sense of completeness in ourselves but also is the sense of belonging to others and to our place; it is an unconscious awareness of community, of having in common. It may be that this double sense of singular integrity and of communal belonging is our personal standard of health for as long as we live.
We practitioners of health sciences and medicine cannot make anything or anyone whole. However, we can partner with clients, patients, farms, religious communities, neighborhoods, grassroots organizations, small business, corporations, and legislators toward a more robust sense of wholeness where the basic principles of our art and science of healing are the necessary daily activities of rest, gathering, eating, and ecology (Berry 1994, 6). This is a thoroughly communal sense of health at the expense of a notion of individual health. Perhaps there is a middle road that acknowledges the mutuality of all living things, the dependence of human health on community, animals, plants, and planet. Even contemporary scientific literature is starting to reflect the idea that a modern definition of health "recognizes that disease and disability can and often do co-exist with wellness. In this new conception, health is transformed from a state that requires the absence of disease to a state where the central theme is the fullness of life” (Bradley, Goetz, and Viswanathan 2018, 207). If we are to define health as human flourishing, it may require letting go of self-determination and individual satisfaction in consideration of “the body's manifold connections to other bodies and to the world.” (Berry 1994, 3)
[1] According to its own website, WHO has not amended this definition since 1948.
Berry, Wendell. “Health Is Membership.” Spirituality and Healing. Lecture presented at the Spirituality and Healing Conference, October 17, 1994.
Bradley, Kent L, Thomas Goetz, and Sheila Viswanathan. “Toward a Contemporary Definition of Health.” Military Medicine 183, no. 3 (2018): 204–7. https://doi.org/10.1093/milmed/usy213.
McKenney, Gerald P. “Bioethics, the Body, and the Legacy of Bacon.” In On Moral Medicine, edited by Stephen E. Lammers and Allen Verhey, 308-323. Grand Rapids: William B. Eerdmans Publishing Company, 1998.
Health. (n.d.). In Merriam-Webster OnLine. Merriam-Webster. https://www.merriam-webster.com/dictionary/health
Hildegard of Bingen. Holistic Healing. Edited by Mary Palmquist and John Kulas. Translated by Manfred Pawlik, Patric Madigan, and John Kulas. Collegeville, MN: The Liturgical Press, 1994. pp. vii-xxii, 1-15, 33-51, 128-138, 174-178, 195-199.
Sweet, Victoria. “Hildegard of Bingen and the Greening of Medieval Medicine.” Bulletin of the History of Medicine 73, no. 3. (Fall 1999): 381-403. doi: 10.1353/bhm.1999.0140.
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