Part 1 - Theory: Thinking About Health
Chapter 1 Concepts of Health and Illness
Definitions of Health
If there are complexities in defining disease, there are even more in defining health. Definitions have evolved over time. In keeping with the biomedical perspective, early definitions of health focused on the theme of the body’s ability to function; health was seen as a state of normal function that could be disrupted from time to time by disease. An example of such a definition of health is: "a state characterized by anatomic, physiologic, and psychological integrity; ability to perform personally valued family, work, and community roles; ability to deal with physical, biologic, psychological, and social stress".11 Then, in 1948, in a radical departure from previous definitions, the WHO proposed a definition that aimed higher, linking health to well-being, in terms of "physical, mental, and social well-being, and not merely the absence of disease and infirmity".12 Although this definition was welcomed by some as being innovative and exciting, it was also criticized as being vague, excessively broad, and unmeasurable. For a long time it was set aside as an impractical ideal and most discussions of health returned to the practicality of the biomedical model.
Health as a Resource
Just as there was a shift from viewing disease as a state to thinking of it as a process, the same shift happened in definitions of health. Again, the WHO played a leading role when it fostered the development of the health promotionhealth promotionactivity that aims to enhance health by education, by organizational, economic and political interventions to support behavioural changes conducive to health. The aims of health promotion include, but also go beyond, preventing disease: it seeks, in addition, to strengthening the skills and resiliency of individuals and of community groups. It differs from health protection which concentrates on removing negative influences. movement in the 1980s. This brought in a new conception of health, not as a state, but in dynamic terms of resiliency, in other words, as "a resource for living".13 The 1984 WHO revised definition of health defined it as "the extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources, as well as physical capacities".14Thus, health referred to the ability to maintain homeostasis and recover from insults. Mental, intellectual, emotional, and social health referred to a person’s ability to handle stress, to acquire skills, to maintain relationships, all of which form resources for resiliency and independent living.
More Detail on Evolving Conceptions of Health In 1977, psychiatrist George Engel had presented the idea of health capacity under the less than catchy title of the biopsychosocial model of health.15 He portrayed disease as the body’s physiological responses to demanding environmental or social triggers; like Susser, Engel saw illness in terms of the patient’s interpretation of symptoms. This interpretation was influenced by the patient’s beliefs and personal relationships, both of which are components of health, or resiliency. He thereby presented health and disease as not merely a continuum along which an individual was situated at any moment, but as a form of interaction between the opposing forces of stimulus or challenge and coping response. Much earlier, Freud had spoken of health as the capacity to love and to work (a view that appeals to some medical students). A person who has the capacity to do what he chooses is healthy; this represented an early shift from an absolute definition to a relative one, and brought health closer to notions of freedom and the subjective quality of life. A corollary is that a patient may have a serious disease yet perceive himself as reasonably healthy if he can still do what he wishes to do: health can thus be viewed in terms of adjustment to reality. Similarly, the notion of healthy aging may be defined as a person’s adjustment to the natural decline in their faculties, as living in balance with their capacities. The process whereby people adjust their expectations downward to match their declining health, and so maintain their satisfaction, is termed response shift.16 |
Wellness
This chapter opened with the theme of rising aspirations and the resulting reconceptualization of disease and health. In response, many practitioners have expanded their focus to include wellness at the positive end of the health continuum. Some distinguish two interacting dimensions: disease versus non-disease and well-being versus ill-being; others expand the number of dimensions to include spiritual, emotional, social, and mental. Last commented that wellness is "a word used by behavioural scientists to describe a state of dynamic physical, mental, social, and spiritual well-being that enables a person to achieve full potential and an enjoyable life".17
But with so much disease to treat, should physicians concern themselves with wellness? Is it appropriate for medicine to seek ways to promote positive health states? Some academics distinguish between a medical care system and a health care system, arguing that, to constrain costs, public funding should be limited to treating illness and restoring the patient’s functional capacity. Others note that activities such as counselling and educating healthy individuals on diet and exercise promote wellness and resiliency, and so fall within the scope of normal practice as a part of preventive medicine. Some go further and argue that physicians should advocate for improved work and environmental conditions, such as promoting walking and cycling rather than driving, and should advocate for policies that redistribute income, limit access to unhealthy foods, and support children’s programs. As concepts of health and disease continue to broaden, there will no doubt be pressure for physicians to expand their role to include the promotion of positive health states in their patients. Reflecting this trend, clinical trials evaluating new pharmaceuticals must now include improved quality of life as an outcome, which obviously extends beyond simply improving biomedical indicators of pathology.
Discussions of wellness eroded the hold of the biomedical model. In its place, ecological models of health appeared; these recognize the complex interactions among people, their personal characteristics and the environment, and how these influence health. An example of this thinking was provided by Trevor Hancock in his mandala of health’.18 This is a model of health and the community ecosystem that represents health determinants as concentric nested influences, beginning with the person at the centre (distinguishing body, mind, and spirit), then moving outwards to the social and physical environment, and then moving further out to culture, economic, and societal influences. The mandala is intended to draw attention to the wide range of health determinants, and to the need to address many levels in developing strategies for improving health.
Figure 1.4 The Mandala of Health.
More recently, a global health perspective has added further rings to the concentric circles to represent the health influences of global climate, economic processes, wars, culture, and the impact of travel in quickly spreading disease. The theme of social determinants of health is discussed in Chapter 2. An extension of the mandala that includes a time dimension is the integrated life courselife coursea perspective in considering the causes of health conditions that traces antecedent circumstances back to early childhood and emphasizes the long-term impact of distant causal influences. and social determinants model of Aboriginal health proposed by Reading and Wein.19, p26 This model represents health influences as a set of concentric spheres (there is a cut-away so that the inner spheres can be seen). The child is at the centre, youth and adulthood in surrounding spheres, and successive layers of determinants outside of these. The inner spheres are segmented to represent the mental, physical, emotional, and spiritual aspects of health.19, p26 This model of aboriginal health is an example of this more integrated complex idea of health. It suggests the time dimension by showing the child growing through youth into adulthood, within the influence of culture and society and the other health determinants.
Figure 1.5. Integrated life course and social determinants model of Aboriginal health19
Spiritual health and Canadian indigenous healing traditions
As conceptions of health broadened, they challenged the traditional western Cartesian tradition of separating mind and body (see Nerd’s Corner box titled "Descartes"). The biomedical model hugely advanced our ability to treat the body but is somewhat less successful in treating the mind. One response has been to adopt medical traditions from other cultures, which commonly emphasize healing rather than treating, and focus attention on the patient’s spirit as well as their body. Spiritual health may be indicated by a sense of peace, hope, purpose, commitment, or worth. For some people spirituality is found through religious practice, while others find it in connection with their values, or in nature, art, sport, or music. A physician who recognizes the relevance of spiritual health may be better able to support her patients, bringing a sense of peace, comfort, strength, love, or connection in order to improve the patient’s sense of well-being.20 For example, chemical dependence is increasingly being considered as having biological, psychological, social and spiritual dimensions.
Before the French mathematician and philosopher René Descartes (15961650), explanations for the observed world were based on a mix of religious beliefs and interpretations of frequently biased observations. Descartes pioneered the open-minded scepticism that characterizes modern science and began by rejecting all forms of preconceptions and beliefs. Science had to consider only what was observable, and the mind was not. Descartes argued that our senses could not be relied on as accurate sources of information, hence proposed a rigid division between mind and body: the Cartesian dualism. |
As an example of a challenge to the Cartesian way of thinking, First Nations, Inuit and Métis indigenous teachings have for a long time recognized other, non-physical dimensions of health.21,22 These various traditions take a broad ecological approach, and consider health in terms of a balance of the spiritual, emotional, physical and intellectual dimensions of a person acting as an individual, but also as a member of a family, community and nation in a variety of cultural, social, economic and political environments. In contrast to Western medicine, which focuses on treating illness, indigenous medical thinking emphasizes healing, which is achieved by restoring balance in the four realms of spiritual, emotional, mental and physical health. Indigenous healing relationships are based on respect, humility, compassion, truth, sharing, hospitality, and divine love. They recognize more routes to healing than biomedical science, and the contrast highlights the dilemma facing modern physicians who aspire to provide health care when they often only have time to treat disease.23 These ideas are symbolized in various ways by different indigenous groups. For the First Nations peoples in Canada, the ideas are often represented by quadrants on a medicine wheel (see the Illustrative Materials box).24 For Inuit peoples, the Learning Blanket has been used as a symbol to explain health and wellness, while there are references to the Métis view of holistic health within the Métis tree model of Holistic Lifelong Learning (see Illustrative Materials box).
In recognition of the relevance of Indigenous concepts of health and healing, the Indigenous Physicians Association of Canada (IPAC) and the Association of Faculties of Medicine of Canada (AFMC) created a set of competency standards for medical students working with First Nations, Inuit, and Métis patients. The competencies are structured around the CanMeds physician roles; they are designed to train physicians to recognize the complexities of the historical relationship between indigenous and non-indigenous peoples, and how this complexity continues to affect the health care provided to indigenous people. The competencies are intended to guide the development of curricula in order to support medical students in developing culturally safe practice when engaging with First Nations, Inuit, and Métis patients. The First Nations, Inuit, Métis Health Core Competencies are available on the AFMC web site at: http://www.afmc.ca/social-Aboriginal-health-e.php
The Medicine Wheel The medicine wheel symbolizes the interconnection of all life, the various cycles of nature, and how life represents a circular journey. It has four quadrants that are often coloured red, yellow, black, and white or green (an illustration is available at http://www.webpanda.com/There/uot_directions-colors.htm). The number four is sacred to many Aboriginal peoples of North America as representing many things: 1) The four cardinal points, each with a guiding spirit, symbolize stages in the life journey. The East, the daily birthplace of the sun, represents a person's beginning and early years. The South relates to childhood and intellectual growth. The West symbolizes adulthood and introspection, while the North represents the old age, wisdom, and the spiritual aspects of life. The centre of the wheel is the axle of Mother Earth and the Creator, representing their role in the beginning and continuation of life. 2) The four points can also represent the balance between four aspects of health: spiritual (East), mental (North), physical (West), and emotional (South). 3) The wheel can represent the process of making decisions. Values (represented by the East, where the sun rises) guide decisions taken in the mental realm (placed in the North, at the top). Then, decisions are implemented in the physical realm (West), and actions produce reactions in the emotional realm (South). These reactions feed back into the value system, completing the circle of value, decision, action, and evaluation. As an example, the loss of traditional values resulting from experiences in residential school could affect health decisions (e.g., consumption of alcohol or loss of traditional diet) that then create an imbalance in the emotional state of a person. 4) The wheel can represent the Four Sacred Medicines: Sweetgrass (the North) is used by almost all Indigenous peoples in North America for ritual cleansing. When sweetgrass is walked on, it bends but does not break, hence its link to virtue: an injustice can be returned by a kindness, by bending, not breaking. Tobacco (the East) is revered as a scared plant: it connects people to the spirit world; it absorbs prayers and carries them to the spirit world and thanks the Creator for his gifts. Traditionally, tobacco was not smoked, except on special ceremonial occasions. Cedar (the South) is used for purification and (taken as a tea) to attract positive energy and emotions, as well as for balance. Its vitamin C content helped prevent scurvy when fruits and vegetables were unavailable during the winter months. Sage (the West) is a medicine for women, conferring strength, wisdom, and clarity of purpose. It is a powerful purifying medicine that drives away negative energies. Sage can be found braided and hung in people’s homes, perhaps tied with a ribbon in one of the colours of the medicine wheel. The threefold braid represents body, mind, and spirit. |
The Learning Blanket A colourful, circular blanket portrays scenes from Inuit life that symbolize the sources of learning and domains of knowledgeculture, people, and sila (life force or essential energy, which derives from the Inuit people’s longstanding relationship with their environment). The experiential learning that occurs on the land affirms the Inuit sense of identity. There are also other sources of knowledge, including languages, traditions, family, community, Elders, land and the environment. All of these are illustrated on the blanket by images drawn from Inuit life. The blanket’s circular shape represents the interconnectedness of all life forms, and the continuous cycle of life, death and regeneration that connects past, present and future. An image of the blanket model is shown at: http://cli.ccl-cca.ca/Inuit/index.php?q=model (accessed September 2010). (Source: the Canadian Council on Learning web site on Inuit Holistic Lifelong Learning: http://cli.ccl-cca.ca/Inuit/index.php?q=home) |
The Métis Holistic Lifelong Learning Model There may not be a broadly accepted Métis conception of health and wellness; various models exist among the different groups. One, for example, describes Métis people as viewing life in terms of a learning process, part of a regenerative, living system, a natural order that governs the passage of seasons and encompasses a community of learners. Within this organic system, relationships interconnect so that balance and harmony are maintained. This may be symbolized by a forest of trees. The tree roots represent the individual’s health and well-being (social, physical, economic, spiritual), providing the conditions that nurture lifelong learning. The trunk contains the growth rings with spiritual health at its core, spanning outwards to the emotional, physical, and mental dimensions of the Métis identity. These evolve over the life course, as more rings are added each year. Knowledge is added like leaves; different branches represent different sources: self, other people, the land, and traditions. A diagram of the tree is shown at: http://www.ccl-cca.ca/pdfs/RedefiningSuccess/CCL_Learning_Model_MET.pdf (Source: the Canadian Council on Learning web site: http://www.ccl-cca.ca/CCL/Reports/RedefiningSuccessInAboriginalLearning/RedefiningSuccessModelsMetis.html) |
Integrative medicine
Contemporary Western medicine is increasingly being challenged to consider how to respond to perspectives and treatments other than those of conventional allopathic medicine (see Nerd’s Corner box "Allopathic Medicine"). One response has been to propose integrative medicine’25 as a collaboration between biomedical approaches and other healing traditions, including herbal remedies, manual interventions such as massage therapy or chiropractic, and mind-body practices such as hypnosis. Similarly, the Canadian College of Naturopathic Medicine trains naturopathic doctors who employ natural therapies as well as using the more standard medical diagnostics of allopathic medicine.
"Integrative medicine is about changing the focus in medicine to one of healing rather than disease. This involves an understanding of the influences of mind, spirit, and community as well as of the body. It entails developing insight into the patient’s culture, beliefs, and lifestyle that will help the provider understand how best to trigger the necessary changes in behaviour that will result in improved health".25 |
In pre-scientific societies, medicine was founded on a mixture of magic, religion, and empirically tested folk remedies. As magic and superstition declined during the Middle Ages in Europe, medicine sought a new basis; it had to be something active that would impress patients, a substitute for the incantations and incense that sceptics no longer respected. The answer that was adopted, and which was much later named allopathy, had been developed long before in the Middle East around the first century B.C. The idea was simple: when the body's workings deviate from the normal, the doctor should try to restore normal function. If a man was feverish, he should be cooled down; if constipated, given a laxative. Illnesses were seen as caused by toxins that should be eliminated. This led to therapies such as bleeding, leeches, enemas, and purgatives. Interventions were often harsh, as depicted cynically in Molière’s plays, and a war metaphor took hold: patients battle disease;’ doctors wage war’ on pathogens and both join forces to fight cancer’. Note that in French, alternative (i.e. non-allopathic) therapies are called médecine douce’, or gentle medicine. The term allopathy was coined by Samuel Hahnemann, who founded homeopathy. Whereas allopathy implies opposing the symptoms of disease, homoepathy implies working with the disease by stimulating the body to produce its natural defensive (e.g., immune) responses. For a time during the mid-nineteenth century, homeopathy (treating like with like) was a serious rival to the allopathic approach, but the development of the germ theory gave allopathy a scientific foundation for many of its remedies. However, by the mid twentieth century disillusionment began when, despite advances in the conquest of infectious disease’ hospitals remained full and waiting lists stayed long. This may have reflected a rising demand for care induced by the perception of its success, but the very success of allopathic medicine (along with improved social conditions) enabled people to live long enough to suffer degenerative diseases for which the allopathic approach is less effective. Moreover, the allopathic approach has some undesired consequences including the rapid increases in costs and the large numbers of people with iatrogenic disorders.2 While allopathic remedies are often highly effective, practitioners are also aware that the best cure may be for the patient to simply restore balance in their life and get adequate sleep, exercise, and good nutrition. |
