health and illness essay

Essay on Health for Students and Children

500+ words essay on health.

Essay on Health: Health was earlier said to be the ability of the body functioning well. However, as time evolved, the definition of health also evolved. It cannot be stressed enough that health is the primary thing after which everything else follows. When you maintain good health , everything else falls into place.

Similarly, maintaining good health is dependent on a lot of factors. It ranges from the air you breathe to the type of people you choose to spend your time with. Health has a lot of components that carry equal importance. If even one of them is missing, a person cannot be completely healthy.

Constituents of Good Health

First, we have our physical health. This means being fit physically and in the absence of any kind of disease or illness . When you have good physical health, you will have a longer life span. One may maintain their physical health by having a balanced diet . Do not miss out on the essential nutrients; take each of them in appropriate quantities.

Secondly, you must exercise daily. It may be for ten minutes only but never miss it. It will help your body maintain physical fitness. Moreover, do not consume junk food all the time. Do not smoke or drink as it has serious harmful consequences. Lastly, try to take adequate sleep regularly instead of using your phone.

Next, we talk about our mental health . Mental health refers to the psychological and emotional well-being of a person. The mental health of a person impacts their feelings and way of handling situations. We must maintain our mental health by being positive and meditating.

Subsequently, social health and cognitive health are equally important for the overall well-being of a person. A person can maintain their social health when they effectively communicate well with others. Moreover, when a person us friendly and attends social gatherings, he will definitely have good social health. Similarly, our cognitive health refers to performing mental processes effectively. To do that well, one must always eat healthily and play brain games like Chess, puzzles and more to sharpen the brain.

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Physical Health Alone is Not Everything

There is this stigma that surrounds mental health. People do not take mental illnesses seriously. To be completely fit, one must also be mentally fit. When people completely discredit mental illnesses, it creates a negative impact.

For instance, you never tell a person with cancer to get over it and that it’s all in their head in comparison to someone dealing with depression . Similarly, we should treat mental health the same as physical health.

Parents always take care of their children’s physical needs. They feed them with nutritious foods and always dress up their wounds immediately. However, they fail to notice the deteriorating mental health of their child. Mostly so, because they do not give it that much importance. It is due to a lack of awareness amongst people. Even amongst adults, you never know what a person is going through mentally.

Thus, we need to be able to recognize the signs of mental illnesses . A laughing person does not equal a happy person. We must not consider mental illnesses as a taboo and give it the attention it deserves to save people’s lives.

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Concepts of Disease and Health

Health and disease are critical concepts in bioethics with far-reaching social and political implications. For instance, any attempt to educate physicians or regulate heath insurance must employ some standards that can be used to assess whether people are ill or not. Concepts of health and disease also connect in interesting ways with issues about function and explanation in philosophy of the biomedical sciences, and theories of well-being in ethics.

1. Introduction

2. naturalism and constructivism, 3. problems for constructivism, 4.1 forms of naturalism, 4.2 specifying causes, 4.3 functions, 4.4 normality and variation, 5.1 health and biology, 5.2 embedded instrumentalism, 6. conclusions, other internet resources, related entries.

Doctors are called on to deal with many states of affairs. Not all of them, on any theory, are diseases. A doctor who prescribes contraceptives or performs an abortion, for example, is not treating a disease. Some women cannot risk pregnancy for health reasons, and historically both pregnancy and childbirth have been major killers. Nevertheless,they are not disease states, and modern women typically use contraception or abortion in the service of autonomy and control over their lives. In addition, it is very difficult to find a philosophically or scientifically interesting cleavage between diseases and other complaints (Reznek 1987, 71–73).

One dominant strand in modern medicine sees a disease as essentially a process that recurs across individuals in slightly different forms: a disease is an abstract kind that is realized in different ways (Carter 2003: Whitbeck 1977). But since a disease is a biological insult, distinguishing it from injury is very difficult. Perhaps injuries are not processes in the relevant sense but events. This essay assumes that the conceptual issues raised by illnesses, injuries and other medical conditions are similar enough to let us put this demarcation problem aside. Disability is another important and neglected topic in health and well-being. It will be addressed here only slightly, since the contemporary debates on disease and disability tend to go on in isolation from each other. Only rarely do authors such as Glackin (2010) tackle both. It is worth noting, though, that the disability debate is typically framed in a way that closely resembles the debate over disease. Medical model adherents judge disability to be the product of a functional impairment or failure in human physiology. This resembles what will be called below the naturalistic model of disease, at least as regards assessment of bodily impairment. It contends that people with disabilities, like people with diseases, are rendered worse off in virtue of these functional impairments, and the explanatory burden of their disadvantage is borne chiefly by the failure of their physiology or psychology to perform a natural function. A concept of disability as dysfunction has been resisted by rival pictures of disability that have made headway in recent decades.

According to the rival “social model”, disability is not a departure from normal or healthy human functioning which makes an atypical condition a “bad difference” from the norm; rather it is a “mere difference” (Barnes 2016). Although disabilities may make people worse off in general, this is due to the way society is set up, rather than any physical impairment. Disability in itself is just variation, analogous to features like sexuality, gender and race. The social model was pushed by disability activists who defined disability as “the disadvantage or restriction of activity caused by a contemporary social organisation which takes little or no account of people who have physical impairments and thus excludes them from participation in the mainstream of social activities” (UPIAS 1975, quoted in Shakespeare 2010). The scientific basis for this position appeals to the idea that “the partitioning of human variation into the normal versus the abnormal has no firmer footing than the partitioning into races. Diversity of function is a fact of biology” (Amundson 2000, p. 34). The resulting partition, it is held, is a reflection of social norms rather than underlying physical impairments. This position resembles what will here be termed the constructivist position with regard to health.

Health has received less philosophical attention than disease, and this essay will correspondingly have less to say about it. The conceptual terrain in the case of health is a little more complex than that of disease; one way of thinking about health says that it is just the absence of disease, so if disease is biological malfunction or abnormality, it follows that a healthy person is someone whose biological systems are all in order. But another way of looking at health insists that it is not just the absence of disease but the presence of something more; a positive state. The constitution of the World Health Organization (WHO) defines health “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO 1948). According to views like this, we should think in terms not of health and disease alone, but in terms of health, disease and normality. This essay will look at theories of health after first discussing disease. The focus throughout is on individuals, although some theorists (e.g. Inkpen 2019) have argued for a seeing humans and their associated microbiomes as part of an ecosystem that can be evaluated, like other ecosystems, as healthy or not.

The tendency in recent philosophy has been to see disease concepts as involving empirical judgments about human physiology and normative judgments about human behavior or well-being (Bloomfield 2001, Boorse 1975, Ereshefsky 2009, Culver and Gert 1982, Thagard 1999). First, we have beliefs about the natural functioning of humans – both our common sense expectations about the body and scientific theories of human biology. Second, we make judgments about whether some particular condition or way of life is or is not undesirable, in some relevant way. This second set of concerns obviously involves normative criteria, to do with the extent to which a life is unnatural, undesirable or failing to flourish in some way. (There is not a clear consensus among writers here.) One important and controversial question is whether the judgments we make concerning our biology are also normative in some way. A further large question concerns the relationship between the two types of judgments, in both medicine and common sense.

Another strain in recent scholarship suggests that our normative judgments alone determine who falls under the concepts of health and disease. This view has been less influential in philosophy, but commands widespread adherence in other areas of the humanities and social sciences (e.g. Kennedy 1983, Brown 1990). Kitcher (1997, 208–9) summarizes the debate as follows:

Some scholars, objectivists about disease, think that there are facts about the human body on which the notion of disease is founded, and that those with a clear grasp of those facts would have no trouble drawing lines, even in the challenging cases. Their opponents, constructivists about disease, maintain that this is an illusion, that the disputed cases reveal how the values of different social groups conflict, rather than exposing any ignorance of facts, and that agreement is sometimes even produced because of universal acceptance of a system of values.

Kitcher’s objectivism is nowadays more often called naturalism, and that usage is followed here. The simple naturalist/constructivist opposition has also been complicated by more recent work and some of those nuances will be introduced here. The next section starts with forms of constructivism and the difficulties they face. Then naturalism will be similarly treated, before the discussion moves to health.

Kitcher’s claim that an objectivist analysis, as he puts it, is “grounded” on facts about the human body is perhaps not as clear as it might be. Before arriving at some qualifications, then, we should have straightforward statements of naturalism and constructivism in hand. (Although, since the qualifications are not yet in place, perhaps no theorist would fully endorse these bald versions of the positions.) There are also taxonomies that cut finer. Broadbent (2019, p.93) argues that naturalism and normativism are only two of the distinctions we need to inform the debate. He thinks of them as “diagonal opposites on a 2×2 matrix of possible positions, being Value-Independent Realism and Value-Dependent Anti-Realism respectively.” Broadbent also recognizes Value-Dependent Realism and his own Value-Independent Anti-Realism. Whether or not constructivist analyses should really be seen as anti-realist in a metaphysical sense is not always clear, though. For reasons outlines below, the philosophical commitments of constructivist views are sometimes hard to grasp.

At the bottom of the naturalist conception of disease (most influentially stated by Boorse (1975) and defended in Boorse (1997, 2014) is that the human body comprises organ systems that have natural functions from which they can depart in many ways. Some of these departures from normal functioning are harmless or beneficial, but others are not. The latter are ‘diseases’. So to call something a disease involves both a claim about the abnormal functioning of some bodily system and a judgment that the resulting abnormality is a bad one. Boorse uses‘illness’ to describe the concept of a disease that causes one’s life to deteriorate. This language is not universal, but the distinction between bodily malfunction and normative judgement is widely used. Naturalists contend that the determination of bodily malfunction is an objective matter to be determined by science. They may also argue (Boorse 1997) that determining whether a malfunction is detrimental to human well-being is also an objective matter, but often they concede that normative considerations are the basis for that judgment. So the naturalist position is that a disease is a bodily malfunction that causes one’s well-being to lessen. This malfunction could take many forms: it is not a necessary part of the naturalist case that diseases constitute a natural kind.

Rather, they could be a set of naturally occurring processes that are held together in virtue of our interest in grouping them as a class. Kinds that work like this include “weed” or “vermin” (Murphy 2006): the existence of the superordinate class depends on human interests but the subordinate members are natural kinds whose natures can be investigated scientifically.

Constructivism, however, argues that human interests do not just define the superordinate class of diseases. It is human interests, not biological malfunctions, that explain the judgments that subordinate members have the relevant biological character. Although constructivists accept that disease categories refer to known or unknown biological processes they deny that these processes can be identified independently of human values by, for example, a science of normal human nature. Constructivist conceptions of disease are normative through and through, although the precise account of the relevant norms will vary between scholars. Analytically, it seems that constructivism is distinct from the claim that disease is normative. However, constructivism and normativism do go together. One reason for this often a professed skepticism about the existence of a non-normative concept of malfunction. More broadly, constructivists may think of disease labels as instruments of social control and reflections of biologically ungrounded reactions to human difference. There may also exist, though this is less often brought to the fore, importantly different stresses on the kinds of value judgements that different theorists think are part of disease categories and their application. Typically, the relevant normative claim is taken to apply to the life of the person whose health is under discussion – it is bad for you to be that way. But in some contested cases the judgments are often held to be wider value-disvalue claims about society more broadly – it is bad for us if you are that way. To make things even more complicated, theorists will sometimes hold that the second type of judgement is what is really doing the work, but it masquerades as the first type. Arguments about disease concepts, as we shall see, are often bound up with political and social controversies in which diagnostic labels are impugned as instruments of oppression or social control.

The key constructivist contention, as seen in the remark by Amundson quoted above, is that there is no natural, objectively definable set of human malfunctions that cause disease. Rather, constructivists assert that to call a condition a disease is to make a judgment that someone in that condition is undergoing a specific kind of harm that we explain in terms of bodily processes. But the bodily processes are not objectively malfunctioning; rather, they are merely judged by us to be unusual or abnormal because they depart from some shared, usually culturally specific, conception of human nature. The crucial difference between the positions then is that for naturalists, diseases are objectively malfunctioning biological processes that cause harms. For constructivists, diseases are harms that we blame on some biological process because it causes the harm, not because it is objectively dysfunctional.

However, constructivism is hard to define satisfactorily, for two reasons. First, its core claim is a denial of the naturalist thesis that disease necessarily involves bodily malfunction. Since there are many views one might hold about the nature of the biological processes involved in disease that are compatible with the denial of malfunction, the positive constructivist claim varies across theories and is often elusive. Reznek (1987) for example, explicitly denies that malfunction is a necessary condition for disease. He does assert (ch 9) that diseases involve “abnormal” bodily processes, but he does not say what that means. Constructivists often, as we will see later, argue that disease judgments appeal to biological processes that are to be understood in terms of human practices rather than membership in some putatively biologically definable class of abnormalities or malfunctions. We have decided that some harmful conditions are the province of the medical profession, and those are diseases.

That brings up the second reason why constructivism can be an elusive target: it has often rested on (perfectly reasonable) claims about the role that value judgments have played in medical practice, or on the prevalence of culturally specific disagreements about abnormal human behavior or physiology. This means, as we shall see, that constructivists, especially in the social sciences, do not tend to offer necessary and sufficient conditions. Rather, they often seek to reconstruct the concept of disease as revealed by our practices. Constructivism, therefore, often looks like a thesis about how inquiry is carried on: first we identify a condition we disvalue, then we look for a biological process that causes it and say that, whatever it is, it is abnormal. This stress on our practices is a common constructivist trope, whereas objectivists more often seek to analyse a concept that will clarify what disease really is, however fumbling and biased our attempts to uncover it may have been.

That both medical practice and lay thought shape disease concepts is undeniable. Because of this, we need to introduce a second distinction. Both naturalism and constructivism can take either a revisionist or a conservative form. A conservative view says that our folk concept of illness should constrain a theoretical picture of health and disease worked out by scientists and clinicians. A revisionist thinks that our existing concepts should be amended in the light of what inquiry uncovers. One could be a conservative or revisionist naturalist, as well as a conservative or revisionist constructivist.

Health and disease, like many other concepts, are neither purely scientific nor exclusively a part of common sense. They have a home in both scientific theories and everyday thought. That raises a problem for any philosophical account: suppose we try to say what health and disease really amount to, from which it follows that the scientific concept should fit the facts about world. If the picture we end up with deviates too far from folk thought, should we worry? You might think that everyday language puts constraints on a concept of health that need to respected, and that if we move too far from ordinary usage we have stopped talking about health and started talking about something else. Furthermore, it is not really possible to argue that scientific and vernacular uses of the concepts are fully independent, since the development of science influences everyday thought, and many scientific concepts begin in pre-scientific contexts and carry the marks of those origins deep into their careers.

Although there is a thriving body of work that tries to analyse the concept of disease – as we’ll see in a moment – other theorists dispute the prospects for a successful analysis of the concept of disease. Schwartz (2007) contends that the biomedical sciences do not share a general concept of disease that is coherent enough to be analyzed. He recommends seeing the proposed analyses as introducing new concepts of disease that are related to existing usage but not bound by it. Concepts so introduced may work in some contexts but not others, and different concepts of disease could be needed for different medical purposes. Hesslow (1993) argues that diseases are not interesting theoretical entities in medicine and are irrelevant to most clinical decisions. These focus on how to improve a patient’s condition and do not need to depend on a judgment of disease.

Furthermore, the concept of disease that is currently employed in most areas of medicine has undergone a process of development. For much of the modern era there has been a dialectic between two concepts of disease. On the one hand, there has been the idea that a disease is just an observable suite of symptoms with a predictable course unfolding. This notion dates back to Sydenham in the late seventeenth century. Kraepelin applied it to psychiatry as the basis for differential diagnosis, for example between subtypes of what was later called schizophrenia (1899, 173–175). The approach was supplanted as medicine matured by the concept of diseases as destructive processes in bodily organs which “divert part of the substance of the individual from the actions which are natural to the species to another kind of action” (Snow 1853, 155; for discussion see Whitbeck 1977, Carter 2003, Broome 2006). This is perhaps still the core medical conception of disease. It seeks explanations that cite pathological processes in bodily systems. More recent medicine has tended to weaken this slightly by adopting what Green (2007, ch, 2) calls an ‘actuarial’ model of disease. This model takes the presence of elevated risk, for example as indicated by high blood pressure, to be a disease even in the absence of overt symptoms or a clearly destructive pathological process (see also Plutynski 2018, ch. 2).

Medicine recognizes illnesses like hypertension and Cushing’s disease that are the outcome of systems in a poorly regulated state that is stable, albeit suboptimal. The idea of a specific pathogenic process in medicine includes dysregulation, but this may not accord with folk thought.

Modern medicine looks naturalistic about disease. One question, then, concerns the extent to which common sense and biomedical concepts are related. Perhaps both have naturalist commitments, or perhaps common sense is driven by values and medicine is not, or perhaps physicians are really constructivists who are self-deceived or arguing in bad faith.

There is little reason to expect scientific and common sense concepts to agree in general, so if medicine and everyday thought disagree about disease, we may ask which concept should be adopted. If we wish to distil a concept that can play a role in medical inquiry, we may side with the scientists. But such proposals, which argue for a sharp separation between scientific and folk uses, are not neutral pieces of observation about the language. They are proposals for purging science from commonsense constraints that hinder its development. A revisionist view of this sort, in this case, says that our concepts of health and disease might be a necessary starting point but should not constrain where the inquiry ends up. Other forms of revisionism are possible. A revisionist naturalist argues that we should follow the science where it takes us and come up with concepts that further scientific inquiry, for example, even if that means that we eventually use the language in ways that look bizarre from the standpoint of current common sense. But a revisionist constructivist could argue that our thought, whether medical or lay, should be reformed in the service of other goals, such as emancipation for hitherto oppressed groups. Such revisionist thought was important in overturning the psychiatric view, dominant until the 1970s, that homosexuality is a mental illness. Activists argued that homosexuality was diagnosed for offensive moral reasons and not for medical ones and the classification of homosexuality as a disease was changed as a result of lobbying on moral grounds rather than on the basis of any new discovery. Naturalists will respond that this was not an example of using constructivism for emancipatory ends, but of bringing psychiatrists to understand that they were not obeying their own naturalist principles about mental disorder, and showing them that there was no good reason to retain the diagnosis. Much debate between naturalists and constructivists involves competing histories in just this way. Constructivists strive to uncover the role that moral and social values have always played in medical diagnosis and argue that our disease categories are hence not properly naturalistic. Naturalists, though they must concede that many diagnoses have been based on moral values that we would now renounce, still insist that the concept of disease, when correctly applied, as it often is, is thoroughly naturalistic and not impugned by past failures by the medical profession to live up to its own scientific ambitions.

Naturalists tend towards conceptual conservatism. They typically appeal to our intuitions about illness as support for their own emphasis on underlying bodily malfunction. This assumes that our current concept is in good shape, that common sense and medicine share a concept of disease, and that medicine should respect lay intuitions about what is or is not a disease. Like many philosophers who think about other concepts with both scientific and common sense uses, conservative naturalists about disease think that folk concepts specify what counts as health and disease. The job of medicine is to look at the world and see if anything in nature falls under the concept as revealed by analysis (cf the “Canberra plan” of Jackson 1998) For revisionists, this understanding of common sense in its relation to science is needlessly submissive to folk intuitions. A more revisionist view takes the relevant concepts to be defined by their role in scientific theories – Boorse (1997) has argued that disease is a term of art in pathology.

Revisionist naturalists argue that facts about physiological and psychological functioning, like other biological facts, obtain independently of human conceptions of the world. Our intuitions might tell us that a condition is not a disease. But scientific inquiry might conclude that people with the condition are really suffering from a biological malfunction. In that case, a conservative would recommend finessing the analysis to ensure that the concept of disease does not cover this case. A revisionist would say that we must bite the bullet and judge that this case falls under the concept even if that judgment is counterintuitive. A revisionist naturalist regards health and disease as features of the world to be discovered by biomedical investigation, and therefore loosely constrained, at best, by our everyday concepts of health and disease. Lemoine (2013) argues that conceptual analysis always involves a stipulative element concerning controversial or borderline cases. Because contending parties will be led by their intuitions to see different stipulations as reasonable, conceptual analysis will be very unlikely to decide between competing analyses that are all reasonably successful at capturing core cases. He suggests that instead philosophers should aim to naturalize disease by trying to first understand general features of theories in the medical sciences and then looking for perspicuous and coherent accounts of different disease types, with a view to eventually establishing an overall picture of the role disease thinking plays in medicine. This approach treats diseases as putative natural kinds and could be highly revisionist, while also leaving open the possibility that some diagnoses represent contingent historical outcomes that have left us with an incoherent category. Fuller (2018) follows Lemoine in dissenting from traditional conceptual analyses. He argues that we should try to work out what kinds of things diseases are rather than worrying about the concept. Fuller reviews the ontological options and asks first about instances of disease – what kinds of things are they? – rather than the concept, but, looking at chronic disease, he goes ‘bottom-up’, by attempting to work out what instances of chronic disease have in common and making inductive generalizations about them. Fuller thinks of diseases – at least chronic ones but perhaps acute cases too – as dispositions (cf Hucklenbroich (2014).

Lange (2007) starts his account of disease from a similar impulse, insisting that diseases play an absolutely essential role in explaining a patient’s symptoms. He argues that this explanatory role is characteristic of natural kinds elsewhere in science, and warrants thinking of diseases as natural kinds. Lange views diseases as natural kinds of incapacities. Stegenga (2018, ch.2.5), discussing Lange’s urging that we dissolve broader disease categories in favour of finer-grained biological descriptions, argues that we should see this as an eliminativist position, since it dispenses with the concept of disease altogether and replaces it with diverse successor concepts. Any theory of disease could advocate for descriptions at finer grains, while retaining a broad category, as Stegenga says, for education and public communication even if it has no real scientific application. The extent to which we should see a theoretical reform as eliminativist or merely very revisionist is hard to answer. In both cases we might secure an epistemic advance, but one might worry that our new vocabularies will deprive people of their ability to understand themselves by replacing a familiar vocabulary with a remote, scientific one tailored to the demands of experts.

Constructivists are usually revisionists. They tend to say that concepts of health and disease medicalize behavior that breaks norms or fails in some way to accord with our values; we don’t like pain, so painful states count as diseases: we don’t like fat people or drunks, so obesity and alcoholism count as diseases. Constructivists will often make this case with special vigor when it comes to mental disorder. The critique of the concepts that guide disease applications is central to constructivism.

Constructivists are often social scientists and their interests may not map neatly on to philosophical concerns. They are not usually interested in conceptual analysis so much as in tracing the social processes by which categories are formulated and changed over time. Conrad (2007, 7–8), for example, says he is “not interested in adjudicating whether any particular problem is really a medical problem… I am interested in the social underpinnings of this expansion of medical jurisdiction”.

But constructivists often present their theories as unmasking common sense or medical conceptions of disease, and hence as a kind of revisionism. They may accept that diagnoses of ill-health involve objective facts that people appeal to, or presume that they can appeal to, when they say that somebody is sick. The assumption might be that germs or other medically relevant causal factors are present in a person and have given rise to visible phenomena that indicate ill-health. But a constructivist will claim that the actual, often unacknowledged, judgments driving the initial assertion that someone is unhealthy are derived from social norms. We may discover facts about obesity and its relationship to blood pressure or life expectancy. But the constructivist says that our search for the relevant biological findings is undertaken because we have already decided that fat people are disgusting and we are trying to find a set of medically significant properties in order to make our wish to stigmatize them look like a medical decision rather than a moral or aesthetic one. The crucial constructivist claim is that we look for the biological facts that ground disease judgments selectively, based on prior condemnations of some people and not others. Because they claim that social norms rather than disinterested inquiry drive medicine (and especially, psychiatry), constructivists tend to be revisionists about folk concepts, seeking to bring to light the unacknowledged sources of our concepts of health and disease. But constructivism could be a conservative view, aimed at uncovering our folk theory of health and disease. A constructivist who takes this view says that our folk concept of disease is that of a pattern of behavior or bodily activity that violates social norms.

The most philosophically sophisticated recent constructionist view is Glackin’s (2019, p.260). He distinguishes the constitution question, which asks for the physical basis of a person’s condition, from the status question, which asks what makes a physical configuration a disease? This way of carving the terrain, and the importance of both status and constitution, is standard among most people who write about disease. The distinctive feature of social construction, in Glackin’s sense, is the priority of value judgements. Glackin uses the grounding relation to supply an answer to the problem of the relation between constitution and status. That is, the frame for grounding is fundamentally evaluative; the normative has a metaphysical priority. As Glackin (p. 262) puts it, disease states are grounded by the underlying biology or behaviour, but this grounding relation exists in virtue of a set of normative facts that provide the frame (in the sense of Epstein 2015: a set of possible worlds that fix the grounding conditions for social facts).

One could be a constructivist about some diseases, and a naturalist about others. For example, one could be a naturalist about bodily disease but a constructivist about psychiatry. Thomas Szasz (1960, 1973, 1987), for instance, is usually read as a constructivist who denies that mental illness exists. But in fact Szasz has a very strict objectivist concept of disease as no more than damage to bodily structures.

Szasz argues that mental disorders cannot exist because they are not the result of tissue damage. He is a naturalist about disease, which leads him to deny that mental illness is real and to offer a critical analysis of our psychiatric practices. And indeed claims that we are merely taking conduct we don’t like and calling it pathological are more plausible in psychiatry than in other parts of medicine, since there is a long history of psychiatrists who have done just that. Samuel Cartwright argued in 1843 that American slaves who tried to escape were afflicted with “drapetomania” or the “disease causing slaves to run away” (Cartwright 2004, 33); slaves were also found uniquely prone to “dyesthaesia Aethiopica”, which made them neglect the property rights of their masters (Brown 1990). Nineteenth century physicians regularly practiced cliterodectomy to cure women of sexual desire, which everybody knew never afflicted normal females of good family (Reznek 1987, 5–6). More recently, Soviet psychiatrists found that political dissidents suffered from “sluggish schizophrenia”. And Horwitz and Wakefield (2007) have suggested that depression has been severely overdiagnosed by recent generations of American psychiatrists, leading to the pathologizing of ordinary sadness.

Our current taxonomy of illness could involve both naturalist intuitions about some conditions and constructivist rationalizations about others. You could use this depiction of everyday thought as a premise in an argument for revisionism, on the grounds that our folk concepts are too confused to serve as constraints (Murphy 2006 makes this argument with respect to psychiatry).

Constructivism seems correct about some putative diseases; that is, societies have at times thought that some human activities were pathological because of values rather than scientific evidence. However, it is another task to show that constructivism is correct about our concept of disease. And this would be true even if there were no diseases; it might still be the case that our concept of disorder is naturalist even if nothing falls under it.

The chief problem for constructivism is that we routinely make a distinction between the sick and the deviant, or between pathological conditions and those that we just disapprove of. Our disease concepts cannot just be matter of disvaluing certain people or their properties. It must involve a reason for disvaluing them in a medical way rather than some other way. Illness has never been the only way to be deviant. So Szasz is just wrong to claim that “when a person does something bad, like shoot the president, it is immediately assumed that he might be mad” (1974, 91). Most of the time when people do bad things nobody doubts their sanity, just their morals. Physically or mentally ill people, even if they are seen as norm-breakers, are seen as a distinctive class of norm-breakers. What’s distinctive about them?

The problem is that we routinely judge that people are worse off without thinking they are ill in any way – for example, the ugly, the poor, people with no sense of humor or lousy taste or a propensity for destructive relationships. We don’t treat these judgments of comparative disadvantage as a prelude to medical inquiry, so why do we do so in some other cases?

Notice that the problem is not just one of establishing that someone is badly off or is in some other disvalued state. Rather, the trouble is caused by the requirement that someone is badly off in a specific, health-related or medically significant way. Rachel Cooper, for example (2002, 272–74), analyzes the concept of disease as a bad thing to have that is judged to require medical attention. She deals with the objection that specifying when someone is badly off is very difficult. Cooper admits that it is a hard problem, but replies that it is a widespread problem, one which crops up in many areas of moral philosophy.

This response is correct as a general point but does not touch the present objection. The objection is not that it is hard to say when someone is badly off, but that it is hard to isolate the specific class of ways of being badly off that we regard as medically relevant without relying on a notion of natural malfunction. Glackin (2019, p.272–3), however, denies that this is a problem at all. He argues that to justify treating some conditions as medical issues, and "others as social or legal, rather than medical, all a normativist needs to say is that this is morally speaking the right thing to do." For Glackin, we can defend the claim that someone is sick by saying that according to our values they are sick, and no more need be said.

Other scholars do think there is more to say. John Harris, for example, posits an “ER test” (2007, 91) according to which we can think of a disorder as a condition that makes someone worse off and is such that emergency room personnel would be negligent if they did not remedy it if they could. But as it stands the ER test is much too broad. Taken literally the ER tests requires medical personnel to teach the local language to immigrants whose lives are worsened by a lack of competence in it. A general theory of ill-being would be as desirable as a theory of well-being. But without further elaboration it would not discriminate between medical and non-medical forms of ill-being. Like Cooper, Harris faces the difficulty of specifying what is distinctively medical about the conditions that we expect medical personnel to treat: of course, a thesis about what counts as a medical intervention that was put in terms of combating disease or pathology would be circular. Reznek (1987, 163) argues that we can delimit a purely medical sphere “enumeratively without reference to the concept of disease – in terms of pharmacological and surgical interventions.” However, as we saw at the start of this essay, a lot of medical attention is directed at conditions which we do not call diseases. Prescribing contraceptive pills is a pharmacological intervention, but it is not directed against a disease; going on the pill is not like beginning a course of anti-malarial tablets.

The naturalist answer to the question what makes some medical interventions directed against disease is that conditions which doctors treat are diseases in so far as they involve natural malfunctions. The constructivist view is that the class of what we call malfunctions is picked out by its involvement in medical practice, and not the other way round. Cooper and Harris try to base their analysis on our practices, but they are unable to distinguish medical practices from non-medical ones.

Broadbent (2019) has a value-independent account, but it is also avowedly anti-realist about disease and so can be treated here. Broadbent calls his view of disease subjective but he has a different way of dealing with the problem of specifying the human response that is characteristic of disease judgments. His theory is that health and disease are secondary qualities like color “that depends on, or perhaps is partly constituted by, the dispositions of observers or thinkers to have certain perceptual or cognitive reactions” (p.108). What human observers bring to physiological states of affairs is not value judgments, but a disposition to track them as making characteristic contributions to survival and reproduction. Broadbent is alert to the issue that there might be cross-cultural differences in judgments about health and disease, but regards these as compatible with very broad agreement on the extension of healthy and diseased states, just as he thinks there is sufficient agreement on spectral phenomena to speak of color in different contexts. The same treatment would need to be given with respect to judgments within a society that vary over time, assuming that objects can change color as a society alters its color categories.

So apart from Glackin there seems to be agreement that the constructivist needs to explain how the judgments that we direct at putative sick or healthy people form a special class of judgments. And that explanation has to show, in addition, why we think the conditions that we single out as diseases with those special judgments are candidates for a particular set of causal explanations. It’s all very well to point out, as Reznek does (p.88) that an etiology only explains a pathology if we have already decided that it is a pathology. This is correct, but it dodges the conceptual question of why we first decide that only some people or conditions are pathological. The naturalist says this: we think some people are worse off because of a special kind of causal process, namely a disturbance of normal physical or psychological function. It is that causal judgment that has conceptual priority, even if, as a matter of timing, the violation of a norm is what is detected first. Note that it does not refute naturalism to point out that the concept of disease is sometimes misapplied, so that we think people are sick but discover that they are not. In such cases (e.g. homosexuality) the explanation for why it happened may be that our values caused the initial judgment, but that does not show that the concept of disease is constructivist, rather than naturalist. No concept is correctly applied every time.

Reznek, for instance, argues that to judge “that homosexuality is a disease we first have to make a value-judgment. We have first to judge that we would be worse off being homosexual” (1987, 212). Reznek then says that we could discover that homosexuality is not a disease if we find out that it develops by a normal psychological process. Reznek calls this is a form of constructivism (or normativism, in his terms) because value judgments have conceptual priority: but in fact in the case he describes it seems that value judgments are actually only heuristics, drawing our attention to whether something might be wrong with someone. If the initial judgment can be overturned by a biological discovery, then it seems that biological facts are necessary for a final judgment. That is to say that our concept of disease necessarily involves both biological and evaluative judgments. That is a version of naturalism, since the biological facts are the ultimate foundation for the judgment. Indeed, naturalism seems to explain why constructivist interpretations are sometimes correct. We say now that homosexuality was never a disease, and was just diagnosed on moral grounds, because it was not caused by malfunctions according to any even moderately correct theory of human biology or psychology. Values stopped people from getting the science right, but homosexuality was correctly understood, and no longer seen as a disease, when the science was done in a properly disinterested way.

Naturalism embodies the important insight that we do in fact think that disease involves a causal process that includes biological abnormalities. It does not mean, however, that all diseases have to receive the same biological explanation. The class of diseases will include a variety of different conditions that receive different causal explanations. That is, even if diseases are natural kinds, the superordinate category of disease may not be. Not just any sort of story about the causes of abnormal behavior will do, and it is difficult to reach a satisfactory specification of the sorts of causes that common sense might recognize. We also distinguish, based on our common sense understanding of human biology, between pathological and non-pathological versions of the same outward phenomena. Because aging is normal we acknowledge that an elderly person will differ from a young adult, so our assumptions about normality are sensitive to background conditions. But when aging is abnormal, we call it a disease. Hutchinson-Gilford progeria syndrome, for instance, causes children to undergo all the stages of human aging at a bizarrely accelerated rate. They nearly always die by seventeen, far gone in senescence. Even though we don’t know much about it, we think of Hutchinson-Gilford as a disease not just because we don’t like being old but because we think it is different from getting old in a way that must be caused by some underlying pathology. The concept of disease necessarily requires, just as naturalism insists, that a condition have a causal history involving abnormal biological systems. So let’s turn to naturalism, and see whether it should be a conservative or revisionist position.

4. Naturalism

When we have decided that someone’s biological systems do not function properly, we still face the question, how should we think about that person’s condition? Naturalists usually admit that there is more to the concept of disease than biological malfunction even if they think that biological malfunction is a necessary condition for disease. This involves a two-stage picture (Murphy 2006, ch 2) which inverts the constructivist portrayal of our practice. Naturalists who buy the two stage picture think that, first, we agree on the biological facts about malfunction. At the second stage we make the normative judgment that the person with the malfunction is suffering in some way. (This is the order of conceptual priority, not the chronological sequence in which judgments are made.) Spitzer and Endicott (1978, 18) for example, say that disease categories are “calls to action”; assertions that something has gone wrong within a person’s body in a way that produces consequences we think we need to remedy (see also Papineau 1994).

Normative considerations, on this account, inform our judgments about disease but do not have the conceptual priority accorded them by constructivists. We make judgments that someone is suffering in ways we associate with inner malfunction. We also see people who are suffering but who we don’t think are ill or injured, because we do not regard their bodily dysfunction as symptoms of disease: vaccination, surgical incisions, ear-piercing or childbirth are examples. Or imagine a skin condition that in some cultures causes the sufferer to be worshiped as a god, or become a sought-after sexual partner. The two-stage picture is designed to distinguish between the physical abnormality and the difference it makes to the life of the person who has it. The idea is that whether someone’s body is not functioning correctly is a separate question from whether it is bad to be like that. Stegenga (2018, p.23) calls such a theory a hybrid account, as it argues both that "there is a constitutive causal basis of disease and a normative basis of disease." He also adds a fourth alternative, which he calls eliminativist, arguing for replacing the notion of disease with successor notions tied more closely to the science. This goes beyond what has here been called revisionist naturalism, in that it advocates getting rid of the disease concept altogether, rather than just liberating it from commonsense constraints. Hybrid accounts have been very popular among naturalists since at least the dissemination of Wakefield’s (1992) influential discussion of mental disorder

The second stage, the question about whether life is worsened by a malfunction, is omitted by simple naturalism. Simple naturalists say that all there is to disease is the failure of someone’s physiology (or psychology) to work normally. The view has fewer adherents, but as noted above, Szasz (1987) uses simple objectivism about disease to justify his claims that mental disorder is a myth, and Boorse has long advocated such a view, as does Williams (2007). The popularity of hybrid accounts, though, is a problem for scholars like Glackin (2019, p. 258), who argues that the debate exists between “normativists, who think the concept is inherently evaluative, and naturalists who think it is purely empirical”. But it is possible to think that there is an empirical question about the causal basis of disease and a further normative question about the judgments made on that basis, which hybrid theorists also think are necessary for disease.

We have arrived at a generic naturalism that says judgments of illness are sensitive to causal antecedents of the right sort, as well as to value judgments about the effects of those causes. What are the right causal antecedents? Culver and Gert’s (1982) requirement that the antecedents be a “nondistinct sustaining cause” is a biologically noncommittal criterion. Culver and Gert analyze the concept of a malady, which involves suffering evils, or increased risk of evil, due to “a condition not sustained by something distinct” from oneself (1982, 72). The cause can be physical or mental, (p.87), provided it is a sustaining cause that is not distinct from the sufferer (p.88). A wrestler’s hammerlock, because its effects come and go with the presence or absence of the cause itself, is an example of a sustaining cause. But because the wrestler is a distinct entity from the sufferer, someone in a hammerlock does not have a malady. If the cause is inside the body it is nondistinct just in case it is difficult to remove (e.g. a surgical implement left behind in the body) or it is biologically integrated in the body (e.g. a retrovirus). This is an attractively simple solution but it is too inclusive. Culver and Gert (p.71) say that loss of freedom, opportunity or pleasure count as evils. But if that is so, then black citizens of South Africa and Mississippi (among many other places) used to suffer from maladies, since they were unfree, unhappy and oppressed. And they suffered these evils because of black skin, which was a nondistinct sustaining aspect of their nature. But it wasn’t a disease. Of course, the presence of racism, backed up by coercive social structures, was also necessary, but aspects of the environment are implicated in many maladies.

This counterexample is instructive, however, since there are two ways of amending the proposal in the light of it. First, perhaps the principle of nondistinct sustaining causes fails to capture our intuitions about causes of disease. A second possibility is that the principle is a good causal condition, but that the account of evils is too broad, and needs to be restricted to a more intuitively medical set of evils, rather than the broader class of impediments to well-being. The section on health will go over the terrain that’s relevant for the second option; the current discussion is about the causal condition. Boorse (1975, 1976, 1977, 1997) and his followers have opted for a more restrictive view of the causes of disease. They contend that disease necessarily involves biological malfunction. Boorse distinguished “disease” from “illness”. The former is the failure to conform to the “species-typical design” of humans, and the latter is a matter of judgments that a disease is undesirable, entitles one to special treatment, or excuses bad behavior. An account of malfunction must be parasitic on a theory of function. Boorse thinks a function is a ‘species-typical’ contribution to survival and reproduction (1976, 62–63). Disease is failure to function according to a species design, in which functional efficiency is either degraded below the typical level or limited by environmental agents (1977, 550, 555, 567; 1997, 32). Boorse understands this as functioning “more than a certain distance below the population mean” (1977, 559) for the relevant set of humans. (Since not all members of a species have the same design in every respect, we need to specify reference classes according to biologically relevant subgroups.) This cutoff point, he thinks, can only be specified as a matter of convention, but this conventional element does not threaten the objectivity of diagnoses. Responses to Boorse since the original theory was formulated have concentrated on two issues. First is the apparent existence of states like tooth decay that are widespread, so apparently statistically normal, yet definitely pathologies. The second is the“line-drawing problem” Schwartz (2007) which comes in two related guises: how we are to reference classes and how we can distinguish between normal and abnormal levels of functional efficiency.

Boorse’s position has been very influential and shaped the entire recent literature. Williams (2007) retains the spirit of the proposal but departs from it in arguing that disease is realized not in systemic malfunctions but failures of interacting cellular networks; he regards applications of disease language to organs, for example, as not strictly speaking correct. Most theorists, though, have continued to emphasis malfunction in physiological mechanisms more broadly. In psychiatry, for instance, Wakefield (1992, 1997a, 1997b), follows Boorse (1976) in assuming that humans have a species-typical design, which he assumes is a product of natural selection. Wakefield applies the picture to both mental and physical illness: in Wakefield’s version we first judge that a psychological mechanism is not performing the function for which natural selection designed it; second, we judge that the malfunction is harmful. An appeal to natural function, by adding extra commitments to the idea of a cause of illness, rules out skin pigment as a cause of evil.

Cooper (2002, p.265) suggests that a straightforward appeal to dysfunction must be qualified in light of some apparent counterexamples. A woman taking contraceptive pills, for example, may be interfering with typical functioning, but ingesting contraceptives is not a disease. (Boorse would have to call it a self-inflicted disease that does not make the woman ill.) Cooper also raises the problem of individuals with chronic conditions that are controlled by drugs. She argues that these are cases of diseased subjects who nonetheless function normally and suggests that the analysis must be amended to talk of a disposition to malfunction. But, as Cooper sees, the big problem faced by Boorsian accounts is that of coming up with an acceptable conception of normal function in the first place.

There are two problems that we can distinguish here. The first is whether a non-normative account of malfunction is possible, about which much debate has taken place. A second problem has come into focus more recently. If there is a positive scientific account of function and malfunction that is pertinent to disease, which science owns it? The debate deriving from Boorse’s work has assumed that physiologists and pathologists have the last word here. Following Boorse, Hausman (2015, p. 9) is explicit that physiologists and pathologists are the relevant medical specialists whose judgments we care about. Lemoine and Giroux (2016) question the great stress on physiology to the exclusion of other medical specialties in Boorse – they think he has backed the wrong doctors. Lemoine and Giroux think we should see physiology as the science of how organisms work considered as assemblies of organ systems. But they think that the science of health and disease is defined by broader medical considerations that go beyond the physiological. Tied up with this is a broad consensus that the correct explanation of disease states is mechanistic, though this too has been challenged in the name of more abstract explanations from different parts of medicine (Darrason 2018).

The Boorsian analysis is of a commonsense concept of disease which bottoms out in a notion of malfunction as the cause of illness. The view is that conceptual analysis determines the empirical commitments of our disease concepts and then hands over to the biomedical sciences the problem of finding biological functions and malfunctions. Some recent theorists, notably Wakefield, have argued for an evolutionary account of function as that which has historically been spread by natural selection. Others have argued that the biomedical sciences employ a different conception of function. Besides identifying the right concept of function for the job, other problems affect the whole naturalist community. A reliance on scientific, functional decomposition as the ultimate justification of judgments of health and disease requires a revisionist, rather than a conservative, account. Also, it may not always be possible to settle contested cases by an appeal to a notion of normal human nature, because that notion is itself contested.

First, why suppose that the relevant concept of function is an adaptive one, and that dysfunction is a failure of a biological system to fulfill its adaptive function? This analysis of function is often termed the etiological account, and although it is widespread in philosophy of biology it seems to be conceptually tied to fitness rather than health (Méthot 2011). Advocates of a thoroughgoing evolutionary approach to medicine (such as Gluckman, Beedle and Hanson 2009) can be read as providing a framework within which we can make sense of a number of processes that have an effect on health and disease, but not as offering analyses of health and disease that are tied to fitness. Gluckman et al. (p.5) consider the difference between lactose intolerance, which develops after weaning and is normal for most human populations, and congenital hypolactasia, a condition in which newborns cannot digest maternal milk. The former is a consequence of the absence of pastoralism in most historical human populations and does not affect fitness in those populations, whereas the latter would have been fatal in the past and thus was selected against. However, they do not define disease in terms of fitness-lowering: they note rather that an evolutionary perspective can make us sensitive to hitherto neglected causes of pathology and also sensitive to over-hasty judgments of pathology in cases where the condition is normal among populations with a given evolutionary trajectory.

Wakefield’s approach is not that of a thoroughgoing evolutionary theorist of disease in that sense. Rather, he plugs an etiological account of function into a Boorsian model, and his approach has been developed with little attempt to argue that medicine does in fact use an evolutionary, teleological account of function. In opposition, Schaffner (1993) has argued that although medicine might use teleological talk in its attempts to develop a mechanistic picture of how humans work, the teleology is just heuristic. It can be completely dispensed with when the mechanistic explanation of a given organ or process is complete. Schaffner argues that as we learn more about the causal role a structure plays in the overall functioning of the organism, the need for teleological talk of any kind drops out and is superseded by the vocabulary of mechanistic explanation, and that evolutionary functional ascriptions are merely heuristic; they focus our attention on “entities that satisfy the secondary [i.e. mechanistic] sense of function and that it is important for us to know more about” (1993, 390).

In effect, Schaffner is arguing that the biomedical sciences employ a causal, rather than a teleological, concept of function. This is in the spirit of Cummins’s (1975) systemic analysis of function as the causal contribution a structure makes to the overall operation of the system that includes it. Cummins’s concept of function is not a historical or evolutionary concept. According to Cummins, a component of a system may have a function even it was not designed or selected for. Wakefield has tied disease conceptually to an evolutionary concept of function as a naturally selected capacity. It is doubtful if this connection can be found in either science or common sense about disease. Perhaps in some areas of biology functional ascription is indeed teleological. However, most theorists who have attended to biomedical contexts agree with Boorse and Schaffner that the function of an organ or structure can be understood without thinking of it as an adaptation. Lange (2007) explicitly follows the systemic approach to function. He argues that diseases are incapacities that explain symptoms in causal-analytic terms.Medical understanding requires that functional structures can be identified and analyzed in terms of their contribution to the overall maintenance of the organism as a living system. However, it is also clear that the contribution of some systems – especially reproductive ones – have a purpose that is not tied to homeostatic regulation and organisation in this way, which complicates the picture. Theorists who prefer a causal-historical account to a teleogical one argue that explanation in medicine takes a model of the normal realization of a biological process and uses the model to show how abnormalities stem from the failure of normal relations to apply between components of the model. This requires a non-historical function concept, one that is at home in causal-mechanistic, rather than evolutionary, explanation. Proponents of a teleogical account can respond that those systems, even if they admit of mechanistic explanation, only exist in the first place because they have facilitated survival and reproduction, and that the etiological perspective provides an overall conceptual framework.

An evolutionary approach faces problems in specifying what the overall evolved function of a system might be and showing how functions contribute to it. First, it is very difficult to assess the relevant evidence that a given biological systems is — as in Wakefield’s treatment — the product of natural selection (Davies 2001, Chapter 5). Since many ailments do not prevent one from living and having children, it is even harder to show that a disease is necessarily the product of a malfunction that lowers fitness or — as in Boorse — interferes with survival and reproduction. Another problem for Wakefield is that if you regard evolutionary dysfunction as partly constitutive of disease then if an illness depends on structures that have no evolved function, it cannot really be an illness. A biological structure might be a spandrel or a by-product, or have some other non-selective history. Such a structure cannot malfunction in Wakefield’s sense, and so it cannot be diseased in the primary, evolutionary sense.The idea would have to be weakened to suggest that it is diseased in a derivative sense in virtue of its implications for other selected effects elsewhere in the system

Objections to an evolutionary notion of medical malfunction do not show that there is anything wrong with the general idea of basing judgments of health and disease on a scientifically established picture of the normal functional decomposition of human beings. However, on this account, it becomes harder to retain the conservative project that looks for the natural phenomena that fall under, and are therefore constrained by, our folk concepts of health and disease. Wakefield, for instance, thinks some psychiatric diagnoses flout our intuitions by attributing disorder on the basis of behavior alone without looking for malfunctioning mental mechanisms (1997a). He appeals to intuitions to derive necessary and sufficient conditions for the folk concept of mental disorder, and assumes that science should search for the psychological processes that fit the concept thus defined. But it is one thing to take intuitions as a starting point, and another to say that they are hegemonic. Boorse, too, adduces everyday linguistic usage and commonsense intuitions as evidence, even though he claims to be discussing the clinical concepts of health and disease.

A revisionist can say that a condition we currently disvalue but do not regard as a disease may turn out to involve malfunction and hence to be a disease, whatever our intuitions say. Conversely, we may think something is a disease but we might be wrong, just as we were wrong about drapetomania or masturbation, which do not causally depend on any biological malfunction. Conservatives resist this possibility. Wakefield claims that we have intuitions about human nature that make it “obvious from surface features” whether underlying mechanisms are functional or dysfunctional (Wakefield 1997b, 256). But it is an empirical discovery whether one’s physiology or psychology is functioning properly, not something to be decided from the armchair, or even from inspecting surface features. A conservative may, though, seek to distinguish debunked intuitions that can be explained away (perhaps as products of local norms, as in the masturbation case) from more resilient intuitions that survive debunking and can still feature as constraint on analysis.

However, once we hand over the task of uncovering malfunction to the sciences we can no longer make common sense the ultimate arbiter, unless we wish to explicitly import, into the concept of disease, considerations derived from folk theories of what normal human nature amounts to.

It seems that the analysis of disease as depending on malfunctioning biological components requires a functional decomposition of human biology. If that decomposition is to be independent of what we think people should be like, it should not be regulated by common sense theories of human nature, but discovered by science. We must be able to ascertain, within acceptable limits of variation, the biological standards that nature has imposed on humans. The goal of finding out how a biological system works is fixed by our interests in health and well-being, but the naturalist’s assumption is that the goal is met by discovering empirical facts about human biology, not our own, culturally defined, norms. So, we diagnose someone as suffering from mesenteric adenitis not just because they are in discomfort due to fever, abdominal pain and diarrhea, but because the lower right quadrant of the mesenteric lymphatic system displays abnormal inflammation. This thickening of the nodes is not just the objective cause of the discomfort, it is an objective failure of the lymphatic system to make its normal contribution to the overall system. For the naturalist’s program to work, the biological roles of human organs must be natural facts just as empirically discoverable as the atomic weights of chemical elements. That may result in the overturning of common sense.

This raises a further issue. It is widely believed that function concepts are intrinsically normative, since they are teleological (for a recent review see Barnes 2016). Therefore, the objection continues, claims about natural functional and malfunction introduce normative considerations into the foundations of medicine, which are supposed to be purely scientific.

A response might be to maintain that whether or not functional claims should be seen as normative, it is not the socially relative normativity appealed to by constructivists. The crucial point is that in the life sciences, some biological system can fail to behave as a theory predicts without impugning the prediction: we can say that the system is malfunctioning. This contrasts with other sciences, in which, if a system fails to behave as predicted, the fault lies with the science, not the system.

Griffiths and Matthewson (2018) attempt to rehabilitate an evolutionary account of function in this context. They tie a selected effects interpretation of function to life history theory, with the advertised aim of providing an explication of pathology that grounds it in a mature science rather than trying to recover some commonsense, or even medically prevalent, concept of disease. Their key contention is that this gives them a scientifically sound way to make discrimination that would otherwise be puzzling, such as the distinction between disease states and senescence, and the means to sort populations into principled reference classes. The resulting picture (Matthewson and Griffiths 2017) is one which generates a variety of evolution-based ways in which organisms can "go wrong". This sets up a taxonomy of opportunities for intervention: some organisms are malfunctioning; others are working properly but in the wrong environment; others are badly off because the environment is inhospitable even though it is normal for them and they are working as they have evolved to; still others generate a development pathway based on misleading information about what optimal development will require. This way of setting up the issues is strongly revisionist, and arguably is no longer an attempt to define disease at all as most of the scholars we have discussed would understand it. Matthewson and Griffiths argue for the congruence of this account with our best science and its stress on the continuity of human and non-human biology.

Supporters of an evolutionary account of function advertise the ease with which an account of malfunction follows from the theory as one of its virtues. Their idea is that we can say when a system is malfunctioning by observing that it is not carrying out the job which natural selection designed it to perform. In contrast, it is widely believed that systemic accounts of function cannot deal with malfunction at all. The argument goes like this: what a system is taken to do is relative to our explanatory interests, and that a putative malfunction can just be understood as a contribution to a different property of the system. Davies (2001) argues that the first of these claims can be defeated by restricting functional ascriptions to hierarchically organized systems in which lower level capacities realize upper level ones. That gives us a characterization of function independent of our explanatory interests.

Godfrey-Smith (1993) argues that systemic concepts of function do permit attributions of malfunction. He argues that a token component in a system is malfunctioning when it cannot play the role that lets other tokens of the same type feature in the explanation of the larger system. Davies (2003, 212) denies this. He says that functional types are defined in terms of what they can do and that if a component cannot carry out its normal contribution to the overall system then it ceases to be a member of a type. However, Davies’ objection appears to fail, at least in medical contexts, if we can identify components apart from their functional roles. Suppose we can identify biological components in terms of their anatomical position and relationships to other organs. If so, we can say that an organ in the position characteristic of its type remains a member of that type even though it has lost some capacity characteristic of that type, and hence is malfunctioning. Reasoning like this permits doctors to identify organs as normal or abnormal during autopsies, even though every system in a corpse no longer possesses its normal function in Davies’s sense.

This leaves unaddressed the issue of how we determine what normal function is. Wachbroit (1994) argues that when we say that an organ is normal, we employ a biomedical concept of normality that is an idealized description of a component of a biological system in an unperturbed state that may never be attained in actual systems. Boorse (1977, 1997) insists that the notion of normality in biomedical concepts is statistical — how things usually are in a reference class, but this view faces the problem of specifying the reference classes in an informative way. But given the amount of variation within a species, it will always be hard to find reference classes which share a design. As Ereshefsky (2009) puts it, Boorse assumes that statistical normality coincides with the kind of normality that medicine cares about, but this looks wrong. Wachbroit (1994, 588) argues convincingly that the role of normality in physiology is like the role that pure states or ideal entities play in physical theories.

Statistically, a textbook heart, for example, may be very rare indeed. But it is the account of the organ that gets into the physiology textbook. The textbook tells you what a healthy organ is like by reference to an abstraction – an idealized organ. This concept of normality is not justified by appeal to a conceptual analysis that aims to capture intuitions about what’s normal. It draws all its authority from its predictive and explanatory utility: against the background of assuming normal heart function, for example, we account for variation in actual hearts (a particular rhythm, say), by citing the textbook rhythmic pattern (which may be very unusual statistically) and identifying other patterns as arrhythmic. The point of textbook depictions of human physiology is to identify an ideal system that enables us to answer “what if things had been different questions” (Woodward 2003, Murphy 2006). The role of an idealization, in this system, is to let us classify real systems according to their departure from the ideal. So normal human biological nature, in this sense, is an idealization designed to let us impose order on variation.

Variation in biological traits is ubiquitous, and so establishing whether a mechanism is functioning normally is difficult: nonetheless, biologists do it all the time. As Boorse notes, many objections argue that pathological states are aspects of natural variation and conclude that there is no clear distinction between the normal and the pathological. But he contends that is a non-sequitur, since the existence of widespread and extensive variation is compatible with the existence of pathological states. Boorse (2014, p. 696–8) and Matthewson and Griffiths (2017) both point out that biologists often judge that members of a species come in forms that are not normal variants but pathological states.

However, how we ascertain what is pathological remains to be determined. Not all diagnoses can be tied to a break between normal and abnormal functioning of an underlying mechanism, such as a failure of the kidneys to conserve electrolytes. Nor can we always discover some other abnormality, such as the elevated levels of helicobacter pylori bacteria that have been found to be causally implicated in stomach ulcers (discussed in detail by Thagard 1999). Some conditions, such as hypertension, involve cutting between normal and pathological parts of a continuous variation, even in the absence of clear underlying malfunctions that separate the populations. The Boorsian tradition has tried to deal with the problem of variation by tying assessments of function and malfunction to reference classes, which Boorse (1977) treated as natural classes of organisms that share a uniform blueprint. Kingma (2007, 2010) has recently argued that reference classes cannot be established without normative judgements, contra Boorse, who takes them to be objectively discoverable parts of the natural order. Kingma contends that Boorse’s account of function needs to capture not only the qualitative causal contribution made by a system to overall functioning, but also the quantitative features of its contribution: a healthy heart is not just a pump, but a pump that works at a given rate. In addition, a system must be capable of working in a variety of situations, including rare ones that require a physiological response to a crisis. Kingma argues that Boorse’s biostatistical theory cannot capture statistically unusual yet functional situations, and concludes that we need to appeal to situation-specific functions. (Cf. Canguilhem (1991 p. 196), who argued that disease is only abnormal relative to a clearly defined context.)

Kingma also points out that organs can become diseased even if they do act in a situationally appropriate way. Liver damage due to paracetamol overdose is obviously not healthy, she says, but the liver is not doing anything situationally inappropriate. That is, a reduced level of function in the context of paracetamol overdose is the situationally appropriate way for the liver to perform. Kingma offers Boorse a dilemma. First, he can either abandon the notion of situationally specific functions. This means failing to recognize the dynamic nature of physiology and leading to absurdities such as the claim that a gut which is not currently digesting because it is empty of food is, in fact, diseased. Or, second, Boorse can acknowledge situation-specific functions, in which case he must say that some systems are healthy (because they are acting as they should in that situation) even though our intuitions insist that they are unhealthy, because there are diseases that are statistically the norm in some situations. Hausman (2011) responds that from a Boorsian perspective the crucial question is whether the normal response – the organism doing its job under stress – renders the system incapable. The digestive system may respond appropriately to poison but in doing so it becomes incapable of normal function on average. If a victim of a poisoning were to a eat a large unpoisoned meal, her digestive system would function much less well than that of the average unpoisoned person in similar circumstances.

Following Boorse, Hausman assumes that there is an average range of performance within a normal population in normal circumstances that can tell us what physiological profile a healthy system ought to have. His reply is developed and expanded by Garson and Piccinini (2014). The issue is whether these normal circumstances can be specified without begging the question, or whether Wachbroit is correct to think of medical normality as an idealization that is unrelated to statistical normality. On any approach, a worry is that if we cite behavioral factors in establishing normality they will reflect contested conceptions of human flourishing. Distinguishing failures to flourish from functional abnormalities will always be a special problem for psychiatry. For example, judgments of irrationality are central to many psychiatric diagnoses, and our standards of rational thought reflect not biological findings but standards derived from normative reflection. The possibility of psychiatric explanation employing the methods and models of physical medicine, then, depends on how much of our psychology is like the visual system – i.e. decomposable into structures to which we can ascribe a natural function (Murphy 2006). Within medicine more generally, the prospects for a general naturalism about disease depend on our ability to understand human biology as a set of structures whose functions we can discover empirically, and our capacity to understand disease causally as the product of failures of those structures to perform their natural functions.

More could be said on all these topics, but the essay will now shift to discuss health. A simple account of health might hold it to be simply the absence of disease, so that if we agree everything is functioning as it should – subject to the complications outlined above, then one is healthy. But most discussions of health insist that health is not just the absence of disease but something more.

As noted above, conceptions of health, like conceptions of disease, tend to go beyond the simple condition that one is biologically in some state. In the case of health, one view is that a healthy individual is just someone whose biology works as our theories say it should. This is the counterpart, in theories of health, to simple objectivism about disease. It is defended at length by Hausman (2015) who calls it “functional efficiency”. As with disease, however, most scholars who write about health add further conditions having to do with quality of life. For instance, Hausman argues that what we are concerned to measure is the contribution that functional efficiency makes to overall well-being. We track not health but the things that make health important. Hausman thus distinguishes disease, health and the value of health. Other scholars draw a similar threefold distinction in different ways. One might have a partly evaluative view of health, like a hybrid view of disease, while also thinking that health should be distinguished from a broader concept like well-being or flourishing. Such views dispute the line we find in Boorse and Hausman that a non-evaluative conception of health is viable. Alexandrova (2018), for instance, argues that health is one of many partly normative concepts that give rise to what she calls “mixed claims“ in the social sciences, that relate, empirical variables to normatively derived variables. The definition and measurement of health, she insists, must depend on normative judgments about what it takes to be healthy.

What kinds of normative claims are relevant? Carel (2007, 2008) thinks that the important thing about health is one’s lived experience of one’s own body, and in particular, that one should not feel estranged or alienated from one’s body. Carel argues that health should be understood phenomenologically as the experience of being at home in one’s lived body, rather than merely the normal functioning of the body seen as a biological unit.

From the naturalist perspective, one problem with this proposal is that it ignores the fact that one can feel perfectly at ease with one’s lived body even if one harbors, unaware, a diseased system. Indeed, Carel argues that someone who is ill can be, in her sense, healthy, if they are adapted to their bodily predicament; from her perspective, objections like the one just mentioned miss the point, since they privilege a biological perspective rather than a phenomenological one. Her project is avowedly revisionist: she wishes to replace existing concepts of health with views that aim to capture the experience of being healthy (or unwell).

Carel’s stress on experience is directly challenged by views like Gadamer’s. He insists (1996, 113) that it is absurd to ask someone if they feel healthy, since health is “not a condition that one introspectively feels in oneself. Rather, it is a condition of being involved, of being in the world, of being together with one’s fellow human beings, of active and rewarding engagement in one’s everyday tasks”. Gadamer’s healthy person is someone who is in harmony with their social and natural environment, and disease is a disturbance of this harmony. Canguilhem (1991, 2012) thinks of health as flexibility, in the sense that a healthy organism can tolerate environmental impacts, adapts to new situations and possesses a store of energy and audacity. This is not something that can be measured by physiology (2012, p.49). Canguilhem’s approach suggests what is wrong with Gadamer’s objection to phenomenological accounts of health. A phenomenological account does not have to hold, as Gadamer seems to have supposed, that there is a special feeling that is the feeling of being healthy. Rather, for a view like Canguilhem or Carel’s, healthy people experience the world as an arena to express themselves in rather than a bunch of threats. Antonovsky (1987) puts this in terms of a sense of coherence which enables one to understand the environment and mobilize internal resources against external stressors. It may well be that perspectives like Carel’s are neglected in contemporary medicine, and that they are especially important in disability studies. However, it does not follow that the concepts of health and disease, rather than aspects of our practices that employ those concepts, should be reformed along the lines she suggests. In general, though, accounts of health, compared to those of disease, are less concerned with trying to capture a scientific or clinical concept.

Gadamer’s view is reminiscent of what Richman (2003) calls “embedded instrumentalist” theories, which claim that health is indexed to goals: how healthy you are depends on how well you can fulfill your goals. Such theories are very popular. Nordenfelt (1995) considered two versions of this approach. One version defines the goals relevant to health as needs, which are understood as having a biological basis. Another view defines goals in terms of the ambitions and desires of the individual. Nordenfelt (1995, 90) argues that a healthy person is one who can satisfy her “vital goals”, which are those that are necessary and sufficient for her to be minimally happy.

Embedded instrumentalist theories of health have an obvious appeal. Once we argue that health involves judgments about how well a person’s life is going, we need a way to evaluate that, and an immediately attractive idea is that someone’s life goes well if they can achieve their ambitions or satisfy their goals. An apparent difficulty, however, is that much the same terrain is covered by theories of well-being, and while people think that being healthy is important to their well-being (Eid and Larsen 2007), they do not identify the two. Rather, they think of health as a component of well-being or a contributor to it.

Some embedded instrumentalist theories, though, appear to be in danger of defining health in such a way that it is synonymous with well-being. Richman (2003), for example, develops his view, (the “Richman-Budson view”) to deal with objections that Nordenfelt raises against goal-based views, such as the worry that someone with very low ambitions will count as healthy just because she is easily satisfied. Richman (2003, 56–57) supposes that someone is healthy if she can strive for a consistent set of goals that would be chosen by an idealized version of herself if she were fully aware of her “objectified subjective interest” (p.45). That is, they are the goals she would choose if she had complete knowledge of herself and her environment and perfect rationality.

In this case it seems that a theory of health is in danger of becoming a general theory of well-being, and Richman does not discuss the relationship between the two. A further complication is the relationship between medical interventions designed to cure diseases, and other medical interventions which are “enhancement technologies” (Elliott 2003). The line between enhancement and therapy is very hard to draw: Harris (2007, 21) for example, uses the example of vaccination, which is both a therapeutic protection against infection and an enhancement of our natural immune system. Perhaps, too, many of us would benefit from a boost to our powers of concentration, or a lift in our mood, which pharmaceuticals might supply. But neurological enhancements, unlike vaccines, can help us to meet our goals without guarding against disease. Perhaps what is needed is a weaker view of the relation between health and goal-directedness, such as that offered by Whitbeck (1981, 620). Whitbeck defines health in terms of the psychophysiological capacities of an individual that support her “goals, projects and aspirations in a wide variety of situations”. This view loosens the tight Richman-Budson connection between health and goal-directed action, and suggests a view on which we can see biological capacities as at the core of health in so far as they help people’s lives to go better. So there seems to be a broad but not unanimous view that whatever one thinks about the value-ladenness of health we need a threefold distinction between disease, health (which may or may not be partly evaluative, and some properties of a person’s life that enable us to evaluate how well it is going for them. Not all such properties are health problems – someone who is oppressed is not unhealthy simply in virtue of being oppressed (though oppression can certainly cause health problems) – oppression itself can be distinguished from the health problems that may follow from the nature of oppression

Schroeder (2013) has taken issue with the whole idea of defining health as a property or state of an individual. He argues in contrast that “health” is a fundamentally comparative term like “tall”. Two human beings can both be tall even if one is taller than the other, whereas it makes no sense to think of two straight lines, one of which is straighter than the other. Schroeder argues that if we see health as fundamentally comparative or relational we can recast several conceptual, ethical and policy debates. For example, instead of thinking in terms of non health-related differences among the healthy we could think in terms of gradations of health. Schroeder also thinks that his approach makes intergenerational or cross-temporal comparisons easier, since we can say that a medieval serf was healthy in their time, but nonetheless less healthy than a modern person who is, by our standards, chronically ill. An approach like this might offer some traction on the reference class problem outlined above.

Naturalism and constructivism have been distinguished for analytic purposes in this essay but they are not always easy to tell apart in practice. The difficulty comes from the fact that there is widespread agreement that our thinking about disease pays attention to both human values and biological phenomena, and it is not always easy to tell how a theorist explains the interactions of these factors, nor whether a given analysis is descriptive or prescriptive. For naturalists the relevant biological processes are departures from good human functioning, construed in one of several ways about which controversy rages, but to be determined by the relevant science. These biological problems result in what we judge to be difficulties in living, which may or may not be partly constitutive of disease, just as positive qualities may or may not be partly constitutive of health. For a constructivist, it is the problems people face in their lives that take priority. Their biological underpinnings are ones we count as abnormal because we have judged them to be both relevant to the conditions we disvalue and also the subject matter of a specific, medical, class of interventions, therapies and other practices. The obstacle to a successful development of naturalism is the problem of establishing a satisfactory, science-based, distinction between normal and abnormal human functioning. Overcoming this difficulty will require a closer engagement by theorists of disease with the relevant debates in the philosophy of biology.

For constructivists, the big problem is to say why we judge some human phenomena to be symptoms of disease whereas others are taken as evidence that someone is criminal or ugly or possessed by demons or something else we do not admire. It is not generally true that we think that if someone’s life goes badly it is because he or she is unhealthy, so constructivists owe us an account of what makes a certain class of judgments distinctively medicalized.

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How to cite this entry . Preview the PDF version of this entry at the Friends of the SEP Society . Look up topics and thinkers related to this entry at the Internet Philosophy Ontology Project (InPhO). Enhanced bibliography for this entry at PhilPapers , with links to its database.

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causation: and manipulability | disability: definitions and models | disability: health, well-being, personal relationships | feminist philosophy, interventions: bioethics | human enhancement | mental disorder | social norms | teleology: teleological notions in biology | well-being

Acknowledgments

The editors would like to thank Patrick S. O’Donnell for bringing several typographical errors in this entry to our attention.

Copyright © 2020 by Dominic Murphy < dominic . murphy @ sydney . edu . au >

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Health, Disease, and Illness as Conceptual Tools

Jimoh amzat.

3 Department of Sociology, Usmanu Danfodiyo University, Sokoto, Nigeria

Oliver Razum

4 AG3 Epidemiology & Intern Public Health, Faculty of Health Sciences, University of Bielefeld, Bielefeld, Germany

There is no absolute consensus on the definitions of health, disease, and illness, even though these concepts are central not only in medicine but also in the health social sciences. A definition of each of the concepts is imperative because they constitute part of the analytical tools in medical sociology. This chapter presents definitions of these concepts, noting that each of them is multidimensional, complex, and sometimes elusive. The WHO’s definition of health is critically examined with respects to its components, criticisms, and alternative definitions of health. This chapter proceeds to discuss the features of a disease and the specific realities of illness by showing the difference between the two concepts. Disease and illness categories (acute, chronic, accidents/injuries, and mental disease/illness) are discussed. The chapter concludes with a strong emphasis on the cultural beliefs regarding illness causation among lay populations, especially in the African context. The natural, supernatural, mystical, and hereditary/genetic causations are discussed based on cultural realities but are sometimes divergent from biomedical models of disease causation.

Introduction

There has not been an absolute consensus on the definitions of health, disease, and illness, even though these concepts are central not only in medicine but also in the health social sciences (e.g., medical sociology, health psychology and medical demography). These are parts of the conceptual tools in various medical-related fields. A definition of each concept is imperative because they constitute parts of the analytical tools in medical sociology. The lack of consensus often prevents uniformity of interpretations and generates more polemics. One wonders why there has not been consensus, despite the long history of medicine. The concepts are multidimensional, complex, and often elusive. For instance, Larson ( 1999 ) observed that disagreements about the meaning of health are common because health is imbued with political, medical, social, economic, and spiritual components. It is subject to various conceptualisation and interpretations. While all the concepts have their foundations in medicine, a biomedical perspective of health or disease may not be comprehensive enough. However, a fusion of the various perspectives often presents a complex definition like the WHO’s definition of health . This is why the debate on the definition of health is still ongoing. That the debate continues is not a problem as refinement of definition could lead to a better conceptualisation.

How Should Health be Defined?

The concept of health presents a form of ambiguity because it is multidimensional, complex, and sometimes elusive. Notwithstanding, various scholars, apart from the definition given by the WHO, have defined the concept. Although it is not the first definition of health, the WHO’s definition will still be the starting point because it is relatively old and has been central to the debate on the meaning of health. WHO ( 1948 ) defined health as a state of complete physical, mental, and social well-being, not merely the absence of disease and infirmity . The definition is holistic, and it presents three major interrelated components of health (see Fig.  2.1 ).

Components of health

• The physical : this is the physiological or biological component of the definition. It simply implies the maintenance of homoeostasis. This is often used to infer a soundness of the body. Most often, disease represents a malfunction of a part of the body system or an intrusion of harmful organisms such as a virus or parasite. This may cause a breakdown of the individual affected. This physiological aspect is the most important biomedical criterion in the determination of health. For someone to be healthy, his/her biological components must be in order. A major diagnosis procedure involves a determination of what could be wrong with any component of the body or detection of any intrusion of any anti-body by tracing the pathways of the disease from underlying causes to pathology in the human body system and examination of any emerging of symptoms. Determining this may involve a series of laboratory tests or clinical examinations. One may be certified as healthy if there is no detection of any biological hitch.
• The social : this represents the behavioural aspect of human health. Being a member of society is being in the network of social interaction and being able to fulfil social roles and expectations. If an individual is not active in the social network, it represents a form of social pathology —an abnormality, which is an infraction on the norms and values of society. The social also incorporates the spiritual dimension. The spiritual aspect could be personal to the individual by connecting to the world of reality and divinity. Larson ( 1999 ) observed that since the WHO’s definition of health, medicine has treated individuals as social beings whose health is affected by social behaviour and interaction.
• The mental : this indicates the psychological, emotional, and mental status of the individual. Emotional apathy, fixation, and maladjusted personality constitute a part of the manifestation of illness. Huber et al. ( 2011 ) observed that the mental aspect of health signifies the possession of a “sense of coherence,” which includes the subjective faculties enhancing the comprehensibility, manageability, and meaningfulness of any circumstances.

The WHO’s definition has been heavily criticised since it was conceived in 1946 after the Second World War (see Callahan 1973 ; Bice 1976 ; Pannenborg 1979 ; Wood 1986 ; Simmons 1989 ; Saracci 1997 ; Jadad and O’Grady 2008 ; Huber et al. 2011 ; Godlee 2011 ; Awofeso 2012 ) . For instance, Awofeso ( 2012 ) observed that the definition is inflexible and unrealistic. He claimed that the inclusion of the word “complete” in the definition makes it unlikely for anyone to be healthy for a reasonable period of time. Godlee ( 2011 ) also noted that the definition is absolute and therefore unachievable for most people in the world. The definition presents an absolute ideal situation by combining the three aspects of human life. It is often difficult, if not impossible, to gain complete contentment in all the aspects. It is observed that since health is a goal, not only of the health care system but also individual and the society at large, it is ideal for a body like WHO to present a realistic definition that can be operationalised and achievable (Godlee 2011 ) .

In addition, Saracci ( 1997 ) also submitted that the WHO’s definition of health is problematic and it should be reconsidered. Saracci observed that the definition equates health with happiness—that a disruption of happiness could be regarded as a health problem. He further argued that the WHO’s definition reflects that health is boundless. More so, Huber et al. ( 2011 , p. 2) opined that the WHO’s definition is problematic because it impliedly declares people with chronic diseases and disabilities definitively ill. The definition further minimises “the role of the human capacity to cope autonomously with life’s ever changing physical, emotional, and social challenges and to function with fulfilment and a feeling of wellbeing with a chronic disease or disability” (Huber et al. 2011 , p. 2) . Despite several decades of criticisms, the WHO has not reviewed the definition. The idea of a definition is to present a holistic view that is meaningful not only for individuals but also as a (definitive) tool in scientific investigation. The idea is not to advance an operational perfection that is unchangeable. Perhaps, there is yet a review because there has not been a more holistic and measurable alternative definition of health. The question is simple: are other definitions of “health” more operational?

A New Definition of Health?

Several other scholars have proposed other definitions of health , which can be used in light of changing global health circumstances. Some of these definitions will be critically examined; however, the essence of examining other definitions is not to defend the WHO’s definition or to render such alternative definitions as immaterial. After some strictures of WHO’s definition of health by Saracci ( 1997 , p. 1410) , he proposed a definition of health as “a condition of wellbeing, free of disease or infirmity, and a basic and universal human right.” Impliedly, this definition also defined those who are living positively with chronic disease as unhealthy. It presents a health as a basic right, which is also problematic. In most parts of the world, health is a commodity with an insurance premium, a price-tag, or it requires a pool from the public tax. This also seems like a theoretical proposition that is not operational. It does not really account for the multidimensionality of health. Therefore, it may not be considered a holistic and viable alternative to the WHO definition.

Bircher ( 2005 , p. 1) , on the other hand, defines health as “a dynamic state of well-being characterised by a physical and mental potential, which satisfies the demands of life commensurate with age, culture, and personal responsibility.” While this is stylishly holistic, it is contentious due to the use of other concepts (e.g., age and culture) without unified definitions. For instance, culture is complex, dynamic, and relative. This may imply that the definition of health will also be relative and probably depend on the circumstances or societies. Additionally, does the definition refer to biological age or social construction of age? This is part of the complicatedness as the concepts used are not specific.

In an attempt to proffer a more acceptable perspective in the face of the continuous debate, Larson ( 1999 ) proposed that health should be conceived using multiple models: medical, the WHO, wellness, and environmental models. A combination of these models will be more holistic beyond the use of only the WHO model or other definitions. Table  2.1 presents the models of defining health. One major problem with model-based definition is that there could be more models than expected. The model-approach does not present a whole definition. Later, every profession will likely present a model of health beyond common understanding, and this will generate more issues. The major strength of this approach is that it emphases the multifactorial context of the concept of health.

Models for defining health. (Source: Larson 1999 , p. 125)

Following the argument that there could be more models, a social model will dwell on Parsonian definition that defines health as “the state of optimum capacity of an individual for the effective performance of the roles and tasks for which he has been socialized” (Parsons 1972 ) . This is more a sociological approach to health—a conceptualisation of health as a social element. Health in this sociological sense is more inclined towards human capacity to fulfil their obligations, participate in social activities (including work), and fulfil role expectations in the society in the face of structural limitations. This conception is connected with both physiological and mental models of health in the sense that the source of a social incapacitation could be from a biological or mental limitation. The social model does not debunk the biomedical model. The model is complementary to the medical model and signifies a perspective that is central in medical sociology .

In a recent development, Huber et al. ( 2011 ) defined health as the ability to adapt and self-manage in the face of social, physical, and emotional challenges . This definition was initially proposed in 2008 (see Jadad and O’Grady 2008 ) . The definition seems to be receiving some considerations, especially because of the use of “adaptation.” While the WHO’s definition stresses on a complete state , this definition proposes adaptive capacity . Lancet Editorial ( 2009 , p. 781) commented, “Health is an elusive as well as a motivating idea. By replacing perfection with adaptation, we get closer to a more compassionate, comforting, and creative programme for medicine—one to which we can all contribute.” The major strength of this definition is that it takes account of the shift in health challenges in the twenty-first century. Unlike the period before World War II when acute diseases were more prevalent than chronic diseases, now the latter constitutes a greater burden. Chronic diseases require behavioural adjustments in terms of self-care or management (see Sects.  2.6.2 and 10.1007/978-3-319-03986-2_8#Sec3 ). This is why the idea of adaptation seems to be more current than that of “a complete state.”

With a critical stance, the definition by Huber et al. is also problematic. First, adaptation does not mean the absence of diseases or infirmity. Adaptation may signify a number of limitations such food or activity restrictions or behavioural constraints. Second, it may also mean continuous treatment or dependence on medication. In the case of a chronic disease, adaptation does not nullify the self-awareness of (undesirable) state of health. The shortcomings of the definition also create opportunities for more deliberations.

Recognising the diversity, relativity and complexity of health, Blaxter ( 1990 , 2010 ) presents a descriptive analysis of health. One of the major dimensions of health identified by Blaxter ( 1990 , 2010 ) is the lay concept of health. This implies how different individuals define health, which explains the relativity of the concept. The lay concept of health is essentially subjective because it is based on people’s own assessment and judgment of whether they are healthy or not. Blaxter ( 1990 , p. 40) observed that the most “usual way of measuring self-perceived illness, as distinct from the presence or absence of disease, is by means of symptom lists.” To the lay population, absence of symptoms means health. From this perspective, Blaxter ( 1990 ) identified the three “states” of health: freedom from illness, ability to function, and fitness. In this regards, health is also perceived as energy and vitality in terms of fitness for functions: physical, social and normative activities .

Blaxter ( 2010 ) argued that health could be defined, constructed, experienced, acted out, and it is also dynamic. Definitions of health are often for operational use like the previous definitions that have been considered. Construction of health stems from the lay perspective or individual’s appraisal of state of health, which can be good or bad. Such construction also includes what a particular society qualifies as “health.” For instance, labelling reactivity (people’s reaction to a particular condition) might influence designation or conceptualisation of health or illness in a particular society (see sect. 10.1007/978-3-319-03986-2_8#Sec5 for labeling theory). Experiential knowledge of health is phenomenological—derived from feeling of wellness or otherwise, which emanate from the presence or absence of personal discomfort and pain. In terms of “enactment” of health, the central consideration includes what people do to maintain their health. Health is also a dynamic attribute because it fluctuates across biographical, historical and contextual milieus. The state of health varies across lifespan, and is influenced by a number of factors including personal (e.g., lifestyle) and structural factors (e.g., access to health care) (see Chapter four). The conceptualisation of disease will be the focus of next section.

Disease as a Conceptual Tool

Health has been conceived in a biomedical model as the absence of disease while the holistic definition from the WHO signifies that health is not a mere absence of disease. Whichever form the definition takes, the question now is “what constitutes a disease?” One major issue is that disease is often conceived from a biomedical point of view. It can also have behavioural manifestations, especially with regard to human functionality. The definition of health is complex, so also is the definition of a disease. If the lack of health can be defined as not a mere absence of a disease or infirmity, this signifies that there are a number of germ- and non-germ-related (medical) conditions that can signify the presence of a disease. This, however, also makes the definition of a disease complex because of variations in its conceptions. Mainly, Boorse ( 1975 , 1977 ) was engrossed in a practical and philosophical discussion of what health and disease may entail. He defined disease as a type of internal state which impairs health (i.e., reduces one or more functional ability below typical efficiency). One major criticism of this definition is the use of “typical efficiency,” which implies the presence of a reference group in the definition of disease (Kingma 2007 ; Stempsey 2000 ) as a kind of comparative analysis. This view is often referred to as a bio-statistical theory (BST) of health and disease. Kingma ( 2007 ) argued that human species are different in functional capacity: what is normal in one group can be abnormal in another and vice versa. Therefore, Boorse’s definition of health or disease is only valid depending on the reference group.

Despite this criticism, Boorse’s arguments have been a significant reference point in the discussion of health and diseases. Boorse discussed seven major themes that are prominent in the discussion of what health or a disease entails. It is important here to examine the seven themes in line with the notion of disease and see how important or otherwise those themes could be in identifying a disease.

• Pain, suffering and discomfort : generally what is called disease accounts for human suffering by inflicting pain and discomfort, sometimes unbearable, thereby necessitating palliative care , like terminal sedation . Whitlow is a typical condition that could impose considerable pain on the sufferer, although it requires a simple medical procedure to resolve. A reason why the argument about pain may not be sufficient is because there are a number of normal procedures that require medical attention as a result of pain and discomfort, but are not diseases, such as teething, menstruation , childbirth , and abortion.
• Treatment by physicians : normally diseases require the attention of medical doctors. A disease should be treatable. However, Boorse submitted that there are some conditions that cannot be treated, and doctors also attend to a number of conditions that are not diseases. With medicalisation of life, there are medical expansions beyond treatment of disease, such as certification of fitness for a study or travel. More so, circumcision, body modification or enhancement, and family planning procedures cannot be regarded as diseases but require attention of a physician.
• Statistical normality : the species’ average level of performance becomes a yardstick for determining normality and abnormality. There is also a measure of statistical normality of clinical variables such as blood pressure, basal metabolism, weight, sugar level, height, pulse, and respiration. Any measure beyond the normal range is usually termed as an abnormality or a disease condition and signifies the need for medical attention. When normal blood pressure ends, there begins hypotension or hypertension . This average of normality is derived from the rate of mortality or functionality within normal and abnormal ranges. It is assumed that mortality or dysfunctionality is often higher when below or above normal ranges. This may not always be the case as clinical variables are measures of probability or propensity to a disease.
• Disability : disease could also lead to many forms of disability. Poliomyelitis is a typical example of a disease that can cause physical deformity. In another case, a disease may reduce active participation of an individual in the social network, such as the inability to walk or stand. Pregnancy , for instance, could not count as a disease even though it comes with some limitations. A number of skin diseases may not count as disease since they may not present with disabling effects.
• Adaptation : the ability to adapt to the environment has also been categorised as a form of healthiness while those who are not fit are presumably diseased. Lack of adaptation prevents an individual from meeting the average level of a species’ functionality. The presence of eumelanin pigmentation in the skins of black Africans helps in adapting to their environment, but it does not mean those with pheomelanin pigmentation cannot survive in Africa or that Africans cannot survive elsewhere. Environmental can even inflict suffering on humans in the process of adaptations.
• Homeostasis : health is a state of bodily equilibrium while disease is a state of homeostatic failure. But the process of human growth as Boorse observed is itself leading to homeostatic disequilibrium .
• Value : disease is undesirable while health is desirable. Health is thus a social value in human society. However, it is also impossible to exclusively delineate disease from the point of undesirability. Conditions such as shortness and ugliness cannot be counted as diseases even though they may not be desirable.

Furthermore, a disease can also be defined as a state in which human capacity fluctuates and represents a deviation from biomedical standard or normal human condition . Disease often requires medical intervention. As noted earlier, not all that conditions which require medical intervention constitute disease. A disease is a pathological state which can be diagnosed through a competent medical analysis. Disease, however, does not always mean there must be a pathological agent such as a virus or bacterium. Conditions such as infertility , gunshot wound, fracture, drowning, and other forms of injuries/accidents also qualify as disease because they represent an infraction on normal human condition.

More so, Fabrega ( 1973 ) explained that diseases usually present with a biological discontinuity . Biological discontinuity signifies the presence of pathology in any part of the body or bodily inactivity due to an injury. Some diseases have pathological agents (e.g., onchocerciasis [worm infection], trypanosomiasis [spread by the bite of the tsetse fly], dracunculiasis [guinea worm], trachoma [bacterial infection], malaria [parasites spread through a mosquito bite]), some are mere deformities or birth defects (e.g., brain injury, autism, spinal bifida), while some are the actual breakdown of organs (e.g., renal failure, blindness) or organ functional problems (e.g., impotency, ectopic pregnancy) . All these diseases have to do with biological problems and constitute apparent forms of diseases.

Furthermore, Temple et al. ( 2001 , p. 807) proposed a definition of disease with three basic elements—“disease is a state that places individuals at increased risk of adverse consequences .” The first element, “a state,” implies a physiological or psycho-social condition which explains susceptibility to risk. Second, risk includes the possibility of impairment. Certain conditions put individuals at a risk of diseases in the future. Therefore, both preventive and therapeutic measures could be provided to avert or ameliorate adverse consequences or undesirable situations. Meanwhile, adverse consequences include morbidity, disability, or mortality. The definition adequately extends to genetic conditions in humans.

Despite these enormous arguments on the biomedical model of disease, it is important to note, as Temple et al. ( 2001 ) observed, that disease is “a fluid concept influenced by societal and cultural attitudes that change with time and in response to new scientific and medical discoveries.” One major example that is often cited is the classification of obesity . In the pre-industrial era, obesity was a sign of affluence and good living, while in the modern era it is a disease with enormous research and development of medical interventions (including surgical procedures) to “cure” obesity. Apart from the medical risks of obesity, the social and modern reconstruction of beauty as a slim body figure also affects attitudes towards obesity. In addition, homosexuality was previously considered a disease but is now normalised in many societies (Nordenfeldt 1993 ) .

The Realities of Illness

Illness and disease have been major traditional concepts in sociology and medical sciences. The important role of these concepts for human-related medical endeavours was re-emphasised by Nordenfeldt ( 1993 ) . These concepts are interwoven and often require some analytical clarifications. Most often, people use the words interchangeable. As conceptual and practical tools, they are not the same. The essence of this section is to make some conceptual clarifications of these concepts and not to join the body of unending debate evident in the works of various scholars (including Boorse 1975 , 1977 ; Hesslow 1993; Nordenfeldt 1993 ; Stempsey 2000 ; Tengland 2007 ) . More importantly, sociologists have laid more claims on the notion of illness because it is more of a behavioural concept than a medical one. Undoubtedly, illness has a number of undeniable social, moral, and legal contexts.

In a simple illustration, disease is a form of pathology or medical problem, defect, or impairment, while illness is a manifestation of such an impairment, defect/pathology, or disability. Illness is a presentation of a medical condition in a way that limits the functional capability of an individual in the society. This is why Nordenfeldt ( 1993 ) observed that to be ill is to be in pain, to be anxious, or to be disabled. The notion of illness fits appropriately into the concept of sick role described by Parsons (1951). It is a situation when an individual consciously feels that he/she is unhealthy, sometimes as a result of discomfort and pain. Therefore, illness is the live-experience of a diseased condition . While a diseased patient might not be real (i.e., without a self-awareness of the condition), an ill patient is real.

It can simply be observed that disease makes people ill . An individual is thus ill to some degree if there is some vital goal of his/her which cannot be completely realised (Nordenfeldt 1993 ) . Illness is a progression from the mere presence of a medical problem or condition to the presentation of disabling symptoms and signs. The underlying meaning is that it is possible to have a disease without being ill and vice versa—invariably it is possible to have a disease without any awareness of it. Boorse ( 1975 ) advanced some clarifications on the character of illness.

• An illness is a reasonably serious disease with incapacitating effects that make it undesirable. It is a condition that is obviously undesirable because of its negative attributes.
• Illness requires treatment. It is a condition, which can be described as a medical problem in terms of impairment, defect, or disability and thus requires medical attention.
• Illness is often a valid excuse for normally criticisable behaviour. This implies that an ill person may not fulfill normative roles and expectations. Instead of criticising an individual, people will affirm that he/she is incompetent due to illness. This implies there is a diminished moral accountability for the ill.
• Determination of illness is bound by appropriate normative judgments or a sociocultural context. This implies that illness is a relative term as it could vary by culture, place, individual, and time. The cultural notion of illness determines the kind of response and how serious some medical conditions could be termed as mild, serious, or negligible.

From the foregoing discussion, it is evident that illness is culture-bound. It is socioculturally defined. This is why Fabrega ( 1973 ) and Garro ( 2000 ) observed that illness is a universal human experience with a cultural meaning. They observed that culture is a tool, which both enables and restrains interpretive possibilities regarding an illness. This cultural interpretation of illness is inevitable and important in a number of ways.

• The first major interpretation is the normative definition of illness, when an individual could be declared ill. In fact, the significant other may play a major role in identifying illness and referring the individual to an appropriate care sector. There are cultural frameworks for recognising a disease/illness through its signs and symptoms.
• The second is aetiological categorisation—an attempt to determine why an individual is ill. Cultural and historical experiences affect this causal classification of illness (see Sect.  2.7 ). If it is an illness that is common in the community, a remedy may be available without much process of diagnosis.
• The third is the evaluation of therapeutic options. This is often influenced by aetiological classification. Different societies have a number of causal explanations. Although natural causation is predominant in western societies, there are other etiological classifications. The same situation applies to the non-western societies. Fabrega ( 1973 ) , for instance, opined that the social definition of illness forms the basis of a decision about medical treatment.
• The last aspect is reintegration into the social system following perceived wellness. This is also very important as the society plays a large role in absorbing a previously ill individual back into the social system. This is often problematic in the case of mental illness as stigmatisation may arise which may eventually affect the illness prognosis.

Disease/Illness Categories

There are various ways in which illnesses can be categorised. For the purpose of this sociological explanation, categorisation based on acute, chronic, accident , and mental illness is adopted. This categorisation also has sociological significance in terms of the dimensions of the diseases. It is also important for medical sociologists to be aware of the nature of diseases and some basic biomedical aetiologies and modes of transmission.

Acute Disease/Illness

An acute illness could be mild, moderate, or severe . Acute illness is by definition a self-limiting disease, which is mostly characterised by a rapid onset of symptoms. These symptoms may be very intense and resolved in a short period of time and, in some cases, could be life-threatening. Most contagious diseases are acute in nature. The term “acute disease” is often an indication of duration of the illness compared to chronic or sub-acute illness. Some examples of acute diseases include influenza or the flu, bronchitis, tonsillitis, sore throat, appendicitis, ear aches, organ failure, and breathing difficulties. Some acute diseases come with the prefix “acute” including severe acute respiratory syndrome (SARS) , acute disseminated encephalomyelitis, and acute bronchitis. Specifically, attributes of acute diseases include:

• Self-limiting : acute diseases have short durations or a limited short course. It is easy to predict that the disease will only last a few days. This also means that the disease could be resolved by itself sometimes without medical intervention.
• Sudden or rapid onset : more often than not, acute diseases inflict humans unaware. An individual may wake up in the morning and discover he/she has the flu. The disease is often rapidly progressive.
• Communicable : most acute diseases can easily be contracted even by mere contact with a sufferer. Sometimes they lead to outbreak (e.g., a cholera outbreak) and kill many people within days of its spread.
• Urgent care : acute diseases often require urgent medical attention. If prompt care is not taken, the individual may die in a matter of a few days or weeks.
• Rapid resolution : most often, response to treatment is very quick. If an individual is hospitalised, it could be for a few days. It means that it can also be rapidly resolved .

Chronic Disease/Illness

The burden of chronic diseases is increasing in the world. Such illness has also been part of the focus of many sociological studies because of peculiar attributes and their increasing burden all over the world. The WHO set a goal to reduce the burden of chronic disease by 2 % every year, thereby saving up to 35 million lives by 2015 (WHO 2005 ). The goal was set following a realisation that chronic diseases are the major cause of death in almost all countries, accounting for up to 60 % of all causes of deaths: 4.9 million people die as a result of tobacco use ; 2.6 million people die as a result of being overweight or obese; 4.4 million people die as a result of raised total cholesterol levels; 7.1 million people die as a result of raised blood pressure (WHO 2005 ). A chronic disease/illness often presents as a medical condition, which makes an individual perceptually and perpetually ill. Major chronic diseases include heart disease and stroke (cardiovascular diseases), cancer , asthma, chronic obstructive pulmonary disease (chronic respiratory diseases), diabetes , obesity , ulcers, sickle cell diseases, and hypertension . Chronic diseases have a significant impact on the population health and by 2015 will be a leading cause of death in Nigeria and many other poor countries (WHO 2005 ).

The characteristics of chronic diseases include:

• Slow onset : this is the major attribute of chronic diseases. It may take several years to develop or to manifest any form of symptom. Smoking takes a long time to affect the smokers. Cancer may take several years to manifest even when one has the risk. Chronic diseases have a slow progression.
• Protracted course : Even when a chronic disease is symptomatic, the sufferer may live with it for several years, especially with proper medical management. For this reason, chronic diseases impoverish millions of (already poor) households because such diseases often gulp a lot of expenditures: its management is usually protracted and expensive.
• Usually non-communicable : chronic diseases are sometimes called non-communicable diseases (NCDs) . One cannot contract a majority of the chronic diseases by mere contact with a sufferer. However, based on the other four attributes of chronic illness/diseases, HIV/AIDS is a chronic disease that can be transmitted from one person to the other (see Sect. 10.1007/978-3-319-03986-2_12#Sec5).
• Chronic diseases are not self-limiting : the medical condition often gets worse with age or time. This implies that they have a long span and are often irreversible. Even when the disease pathogens are removed, the condition may reappear .
• Treatable but not curable : chronic diseases are preventable, and they can also be managed, but a majority are not curable. This is why the diseases constitute a major health burden in the world today.

Injuries or Accidents

Injuries or accidents also constitute another form of health problem. An injury is usually sudden and may lead to a serious or permanent disability or death. Most of these medical conditions are always in the emergency unit or on a priority list in any triage system. Road accidents are the major sources of accidents especially, in the developing world. Workplace injuries also account for a substantial number of deaths each year. Most accidents are usually unintentional and random. Injuries or accidents include drowning, fire-related burns, fall-related injuries, poisoning, interpersonal violence , self-inflicted injuries, and war injuries. Approximately, more than 5 million people die and over 100 million suffer from non-fatal injuries (sometimes permanent disabilities) annually (Peden et al. 2002 ; WHO 2010 ) . While the global percentage of deaths from road traffic injuries is about 25 %, the percentage in Africa is about 45 % (WHO 2010 ). Figure  2.2 shows the global distribution of injuries by cause. Management of injuries require rapid and responsive health care and other relevant agencies.

The global burden of injuries by causes. (Source: Peden et al. ( 2002 , p. 9) )

Mental Disease/Illness

Mental health simply refers to the level of psychological well-being of an individual. This often has to do with the brain vis-à-vis thought, feelings, sensation, and intuition. About 14 % of the global burden of disease has been attributed to neuropsychiatric disorders (Prince et al. 2007 ) . Mental problems frequently manifest with behavioural changes that represent an infraction on the social norms of the society. A mental disorder is socially disastrous to the individual and could lead to total incapacitation or exemption from normal roles in the society. There are two major divisions of mental illness, which include neurosis (minor) and psychosis (major). While the former does not usually involve organic (brain) breakdown, the latter usually does. Examples of neurosis include: obsessive-compulsive disorder, anxiety disorders, post-traumatic stress disorder, phobia, dissociative disorder, minor depression, hypochondria, hysteria, and puerperal neurosis. Psychosis involves loss of contact with reality. It is generally the worst form of mental disorder. Examples of psychosis include bipolar disorder, schizophrenia, depression, substance-induced mental disorder, dementia (Alzheimer), delusional disorder, and epilepsy. A mental disorder may not necessarily lead to death, but it is disabling—it could be acute or chronic. Sartorius ( 2007 ) observed that stigma attached to mental illness is the main obstacle to the provision of care for people living with mental disorders. The stigma is a mark or label on those who are ill and their generations (see Sect. 10.1007/978-3-319-03986-2_8#Sec6 for the theory of stigma).

Cultural Beliefs of Illness Causation

In all cultures, there are cultural classifications of disease aetiology or lay understanding of illness. This is usually based on the traditions and belief systems. This implies that cultural beliefs affect the perception of aetiology of diseases (Sylvia 2000 ) . Most of these beliefs are not coherent with the biomedical beliefs and are sometimes unscientific. Irrespective of value judgment about such beliefs, the realities of such beliefs cannot be debunked, so also the realities of such causal connections. It is often the case for scientists to consider some local beliefs about causality implausible, inexplicit, and inconsiderable in scientific explanations. However, local beliefs are relevant in understanding the population health and in drawing behavioural interventions. Sometimes, such beliefs are misconceptions, which need to be addressed. Specifically, disease causation is often divided into four types: natural, supernatural, mystical, and hereditary/genetic.

Natural Causes

A natural cause refers to the biomedical explanation of a disease. This conforms to the germ theory of disease. The explanation is based on pathogenic causation such as microbial agents including viruses, bacteria, worms, and fungi. This also includes injuries and accidents such as broken bones and the ingestion of bad substances into the body. O’Neil ( 2006 ) observed that other forms of natural causation include :

• Organic breakdown or deterioration (e.g., tooth decay, heart failure, senility)
• Obstruction (e.g., kidney stones, arterial blockage due to plaque build-up)
• Imbalance (e.g., too much or too little of specific hormones and salts in the blood)
• Malnutrition (e.g., too much or too little food, insufficient proteins, vitamins, or minerals)

This explanation is sometimes called mechanistic or naturalistic explanation of disease causation. The diseases categorised with natural causes can be clinically or medically diagnosed. Traditional African societies hold a coherent view on the biomedical explanation of illness as it relates to natural causes, although some diseases may be explained based on multiple causalities . For instance, small pox may be explained from a natural cause, and it can also be attributed to anger of the god of small-pox (called Sanpanna ) among the Yoruba of western Nigeria . This means that, despite the natural cause attached to a disease, there could be other explanations, and sometimes multiple therapies have to be employed.

Supernatural Causes

There is also a supernatural causation of illness. As Conco ( 1967 ) and Omonzejele ( 2008 ) explained, this is the spiritual construction invoked to explain the “uncommon or out-of-the-ordinary” types of sickness. It is further observed that it is made use of at a point where ordinary empirical methods of treatment and explanation have failed. This typically deals with divine attribution of illness. With the emergence of modern religions, such as Christianity and Islam , there is attribution of diseases to God. Such diseases may come as punishment for misdoings or sins. References to divine infliction of diseases/plagues can be cited from both the Bible and Quran in historical times. Especially among most religious adherents, there is a fatalistic belief that disease or health comes from God. Such infliction will usually present with medically unexplained symptoms or with medically explained symptoms that are beyond medical remedies. This is a part of the belief system and such diseases require pleasing the God through repentance, fasting, and prayers.

Disease could also come from the gods, spirits, deities , and other supernatural entities such as wizards and witches. This traditional perspective of illness describes a different source of evil (illness) caused by invisible spirits that exist within and outside human social boundaries (Foster 1976 ) . These spirits inhabit trees, rivers, lakes, mountains, and deserted places around the habitation (Bhasin 2007 , p. 6) . In most African societies, there are gods or deities of the land who need to be appeased from time to time, both at the individual and community levels. Lack of appeasement from either of the levels could be detrimental. The people of the Kalahari Desert also attribute diseases and health to Hishe (god). So also the Bantu of South Africa (like many other groups in Africa) believes that supernatural entities can inflict pain or disease on individuals. Conco ( 1967 , p. 288) specifically explained that

[i]n varying degrees most rural Africans believe that it [supernatural causation] explains all complexes of extra-ordinary diseases. They also believe that it is true, and this implies that they are psychologically convinced, though they cannot give conclusive empirical grounds for its truth. It is a metaphysical article of faith, and as such it cannot be verified or falsified empirically, though it always has some claim to being factual.

The belief in supernatural causality is widespread in both rural and urban communities and across groups whether educated or not. Foster ( 1976 ) and Garro ( 2000 ) noted that, among several people, there is a wide belief in the supernatural cause of illness: the Mono of Liberia and Abron of Cote d’ivoire believe that death is usually caused by external forces. Jegede ( 2002 , 2005 ) observed that among the Yoruba of western Nigeria , illness can be traced to enemies ( ota ), witchcraft ( aje ), sorcery or wizard ( oso ), gods ( orisa ), and ancestors ( ebora ). The belief of the supernatural causes of illness is still highly prevalent and central in the explanation of illness in Africa (Omonzejele 2008 ) .

In cases of supernatural causes, diseases are diagnosed through spiritual means, especially through consultation with religious clerics or traditional healers. It is believed that these categories of people have spiritual power to detect and prescribe a course of action in the treatment of illness. Such therapeutic procedures are not amenable to science or are simply beyond empirical comprehension and explanations.

Mystical Causes

The mystical causes are a part of what Foster ( 1976 ) described as a personalistic cause of illness . Mystical retribution is defined as acts in violation of some taboo or moral injunctions, which could lead to illness (Murdock 1978 ) . In traditional African societies, illness can result from the violation of vital norms and values of the society. These norms are often concerned with the traditions and spirituality of the community. Specifically, many African societies believe that some individuals have “evil eyes” or possess a mystical power that can be used to inflict pain or illness on other people in the society.

Illness as a result of mystical causes also present with symptoms that cannot be explained medically or where explanation is possible, biomedical treatment is futile. Such patients are often referred to the traditional or faith-based healers for appropriate deliverance or salvation from such illness .

Hereditary and Genetic Causes

Hereditary diseases can be passed from one generation of same family to another . While heredity is linked with genetics , not all genetic disorders are heritable. Most hereditary or genetic diseases have natural causes, and some of them can be explained from supernatural causes . Many African societies (e.g., the Yoruba of West Africa) believe that madness can be inflicted on a family and it can continue from one generation to the other. The Yoruba call hereditary disease aisan idile , literarily translated as “a family disease.” Treatment depends on the perception of the aetiology, whether natural or supernatural. Some biomedical hereditary/genetic diseases include autism, cancer , dwarfism, sickle cell anemia, cystic fibrosis, albinism , color blindness, myotonic dystrophy, porphyria, and some forms of mental illness (e.g., Huntington’s disease). Hereditary diseases have effects on the relationship patterns in the society as many individuals may not marry from a family where a hereditary disease is perceived to exist.

One critical way of perceiving hereditary or genetic disease is through fatalism, especially among Islamic communities of Africa . This is the attribution of such a condition to the will of God claiming it has been destined that a person would have such a medical condition. The Yorubas call this kadara or ayanmon (i.e., destiny). Especially in heritable genetic disorders in children and adults, this fatalistic idea prevails. The idea can also be applied in cases of injuries and accidents . This idea serves as a coping mechanism and aids reintegration into the society. Since it is the will of God, discrimination is termed against the will of God. It helps the individual to live and surrender to destiny, fate, or an act of God. Unfortunately, the idea does not help in preventive measure. Fatalistic individuals tend to accept everything that comes their way—if it has been destined, it is beyond human preventive measure.

In conclusion, this chapter has dealt with a lot of issues regarding health, disease, and illness. It starts with the polemics on the definition of health by de-constructing some of the available definitions. In the case of health, the goal is to work towards a state of perfection. No matter how health is defined, nobody can be in a perfect state—whether “adaptation” or “a state of completeness” is used. This argument does not, however, mean that available definitions should not be reviewed .

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• Published: 18 March 2020

A philosophy of health: life as reality, health as a universal value

• Julian M. Saad   ORCID: orcid.org/0000-0002-9323-1021 1 &
• James O. Prochaska 1  

Palgrave Communications volume  6 , Article number:  45 ( 2020 ) Cite this article

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• Health humanities
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Emphases on biomarkers (e.g. when making diagnoses) and pharmaceutical/drug methods (e.g. when researching/disseminating population level interventions) in primary care evidence philosophies of health (and healthcare) that reduce health to the biological level. However, with chronic diseases being responsible for the majority of all cause deaths and being strongly linked to health behavior and lifestyle; predominantly biological views are becoming increasingly insufficient when discussing this health crisis. A philosophy that integrates biological, behavioral, and social determinants of health could benefit multidisciplinary discussions of healthy publics. This manuscript introduces a Philosophy of Health by presenting its first five principles of health. The philosophy creates parallels among biological immunity, health behavior change, social change by proposing that two general functions— precision and variation —impact population health at biological, behavioral, and social levels. This higher-level of abstraction is used to conclude that integrating functions, rather than separated (biological) structures drive healthy publics. A Philosophy of Health provides a framework that can integrate existing theories, models, concepts, and constructs.

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A philosophy of health.

What is health? Is it a state of the body or the mind? Is health primarily a natural, biological state or a holistic, value-laden state? Naturalistic and holistic philosophies of health have provided very important, but very different, perspectives of population health. Naturalistic views (e.g. as seen in Boorse, 1997 ) provide insight into physical, natural, biological, or physiological processes that are tangible (in the material sense), observable, and measurable with modern technology. Complementarily, holistic views contend that value-laden phenomena (e.g. vital goals, meaning, and purpose) play a central role in population health (Nordenfeldt, 2007 ).

A dialog, or as we see it, an important dialectic among naturalistic and holistic perspectives plays out between the Biostatistical Theory of Health (BST) and the Holistic Theory of Health (HTH). The BST posits that a person is healthy if and only if, all natural organs function normally given a statistically normal environment (Boorse, 1997 ). The HTH posits that a person is healthy if and only if (given standard circumstances) he/she has the ability to attain their vital goals (Nordenfeldt, 2007 ).

In addition to defining health, each philosophy defines disease. The BST poses that disease is the internal state of impairment to the normal functioning of organs (Boorse, 1997 ). In the HTH, an organ dysfunction is a disease if and only if the organ’s process reduces the person’s ability to pursue vital goals or life-purpose (Nordenfelt, 2007 ). In BST health is the absence of disease; and in HTH, health is not the absence of biological disease, but is the whole person’s ability to function in relation to vital goals.

Both naturalistic and holistic perspectives guide important observations of health and disease. When one considers health through the BST one pays close attention to the functions of the internal, biological functioning of the human being. When one considers health through the HTH, one pays close attention to the functioning of an individual, in relation to their external, societal/cultural functions. Is there a hybrid model that accounts for both internal and external functioning?

Wakefield’s ( 2014 ) harmful dysfunction analysis (HDA) creates a hybrid model that integrates natural- and value-laden phenomena when conceptualizing disease. HDA asserts that a person suffers from a disorder/disease if (1) the condition causes harm (as judged by the standards of the person’s culture); or if (2) the person’s internal, natural processes cannot perform normal functioning (as judged by the standards set by evolution). HDA creates a hybrid model that can integrate perspectives of the BST (i.e. by considering internal organ functioning); and the HTH (i.e. by considering external societal/goal functioning). However, while HDA may define health processes in relation to disease, it serves primarily as an integrative model of disease . Is there an integrative model of health that can account for natural and value-laden functions?

Schroeder ( 2012 ) identifies a significant, common thread among these competing (or perhaps complementing) philosophies: functionalism . The researcher suggests that each philosophy is concerned with the functioning of organisms. Although the BST, HTH, and the HDA might not agree on which functions inform the first principles of health, Schroder ( 2012 ) uses higher-level abstraction to identify one common first principle: the state of functioning in an organism impacts its state of health . When paralleling the three philosophies based upon functioning one might observe that (1) BST declares an individual healthy if its organs function normally; (2) HTH declares an individual healthy if he/she can function in relation to vital goals; and (3) HDA declares an individual unhealthy if internal mechanisms cannot perform natural, evolutionary functions, and/or when a condition prevents a person from functioning in relation to goals/norms/values. Through this higher-level abstraction, an integration of seemingly separate philosophies of health is made possible.

Learning from leaders in the field

As we attend to these philosophies of health, we too observe how discussions about functions and functioning produce integrative perspectives. Although a definition of “function” is not explicitly stated in the above research, it appears that Nordenfeldt ( 2007 ), Boorse ( 1997 ), Wakefield ( 2014 ), and Schroeder ( 2012 ) are each discussing functions as pre-existent (i.e. either from evolution, personal goal-setting, cultural tradition) processes - with - purposes . Whether one is describing a value-laden function (e.g. decision-making in pursuit of a valuable career) or an evolutionary-biological function (e.g. the heart beating for circulation), each process (i.e. decision-making processes or cardiac processes) serves identifiable purposes (e.g. maintained financial stability or maintained blood flow). Whether an organ is functioning normally in relation to the body or a human being is functioning in relation to vital goals, it appears that both perspectives consider if an active “process” (i.e. an organ’s activity, an individual’s activity) can express its “purpose” (i.e. evolutionary-purpose, life-purpose).

In the present manuscript we will propose that naturalistic and holistic perspectives can be integrated within a single philosophy of health. We will propose two universal functions—termed precision and variation —that can account for both natural functions and value-laden functions of the existing philosophies. This functional language will support a higher level of abstraction that integrates, rather than separates, biological functions, behavioral functions, and social functions under A Philosophy of Health.

The need for new perspectives in population health

The chronic disease crisis beckons the need for an updated philosophy of health that can account for biological, behavioral, and social functioning. Why? Chronic diseases, which account for 60% of all-cause deaths worldwide (Chartier and Cawthorpe, 2016 ), do not emerge from naturalistic, biological, or physical contact with an illness. Rather, chronic diseases do emerge in biological functions (e.g. tumor proliferation in an organ) after prolonged contact with health risk behaviors and lifestyle factors that active the conditions (Mokdad et al., 2018 ; Edington, 2009 ; Li et al., 2018 ). Chronic diseases are not curable by purely naturalistic or biological means (e.g. pharmaceuticals). Rather, some diseases may be effectively prevented or intervened on through healthy behavior (Dansinger et al., 2005 ; Daubenmier et al., 2007 ).

Population health risk behaviors are unique determinants of population health because researchers can actively observe how they simultaneously alter biological functioning (e.g. chronic smoking alters cells in lung tissue), behavioral functioning (e.g. chronic smoking alters decision-making and daily habits) and social functioning (e.g. chronic smoking creates an economic, social, and healthcare burden) of the population. These behaviors not only have biological, behavioral, and social implications for the individual doing the behavior, but also have intergenerational and interpersonal effects. The individual who binges on refined sugar not only puts themselves at risk of diabetes, but can put their future offspring at risk. The individual who smokes two packs of cigarettes per day not only puts themselves at risk of lung cancer, but can put their housemates at risk of lung cancer from second-hand smoke. Therefore, the chronic disease crisis is neither purely naturalistic, nor purely value-laden; rather it reflects an integration of natural and value-laden phenomena. There remains a real need for principles of health that can integrate existing naturalistic and holistic perspectives of population health.

The principles

Since April 7, 1948, the Constitution of the World Health Organization ( 2010 ) has utilized an intuitive definition of health by suggesting that health is “a state of complete physical, mental, and social well-being.” While this definition might be intuitive and even accessible to a wide audience; the defininition is not necessarily researchable across health disciplines. Integrating principles of health might begin with a common-sense definition of health that can also be upheld across existing naturalistic and holistic perspectives. Without operationally defining functions that drive physical, mental, and social well-being, it is a challenge for multidisciplinary collaborators to unite under the WHO mission. Further, without a common definition of health, important communications from patients to doctors, from subjects to researchers, from researchers to collaborators, and from peer-reviewers to peer-reviewees, can become fragmented or lost in translation. In the proceeding sections, a common-sense definition of health is used to present the first principles of A Philosophy of Health.

Principle 1: “Health” is the state of maintainable-ease of functioning . A “disease” is a state of prolonged-dysfunction that prevents ease

Chronic diseases emerge from prolonged exposure to dysfunctional behaviors like smoking, alcohol abuse, unhealthy diet, and inactivity (Mokdad et al., 2018 ) that also create dysfunctional expressions of life functions. Smoking creates dysfunctional breathing; alcohol abuse creates dysfunctional drinking; sugar binging creates dysfunctional eating; and sedentary behavior creates dysfunctional moving. When these health risk behaviors lead to chronic disease, they have already prolonged dysfunctional breathing, drinking, eating, and/or moving.

The chronic smoker breathes in smoke so frequently that he no longer experiences an ease-of-breathing. Rather, his breathing becomes short and shallow. Prior to the emergence of lung tumors, the chronic smoker prolongs dysfunctional patterns of breathing. The “couch potato” sits so frequently that he no longer experiences an ease-of-movement. Rather his movement becomes rigid and limited. Prior to the emergence of cardiovascular dysfunction or obesity, the sedentary person prolongs dysfunctional patterns of movement.

If chronic smoking facilitates prolonged-dysfunction in breathing, and sedentary behavior facilitates prolonged-dysfunction in movement, what do functional breathing and moving look like? Healthy breathing and moving (as well as eating and drinking) are characteristic of an ease of one’s functioning that can be maintained in normal conditions. For example, the chronic smoker and the “couch potato” might report momentary-ease in breathing and posture when engaging in their health risk behaviors; but they do not maintain that ease outside of smoking or sitting. Conversely, the yogi might report that their yoga practices expose them to momentary dis-ease in breathing and moving that lead to maintainable-ease in breathing and movement in everyday life. In contrast to disease as a prolonged-dysfunction, healthy functioning can be commonly sensed as a maintainable - ease of functioning .

When observing a disease, perhaps we are observing a prolonged-dysfunction that prevents ease. Rather than define health as the absence of disease (as seen in BST), notice here how we instead define disease in relation to health; and we define health in relation to maintainability , ease , and functioning . Consideration of “maintainable-ease of functioning” will allow us to consider how not all “dis-ease” is bad (i.e. exposure to acute dis-ease/stress maintains healthy functioning in the long-term); and not all “ease” is good (i.e. avoidance of stress and prolonged “comfort” creates fragility seen in sedentary behavior). We propose that:

Dysfunction parallels a state of “dis-ease”; and prolonged -dysfunction parallels the state of Disease.

Function parallels a state of “ease”; and maintainable-ease of functioning parallels the state of Health.

This definition of health will be applied in the proceeding principles to integrate naturalistic and holistic perspectives of population health.

Principle 2: Health emerges from maintainable-ease of functioning at multiple levels . Maintainable-ease of functioning in the general population can be observed at the level of the cell , the self , and the society simultaneously

Cooperation across multiple levels of functioning is required for the organization and adaptation of living systems (Nowak and Sigmund, 2005 ; Antonucci and Webster, 2014 ). When developing an integrative model of health, it is important to consider how biological cells, individuals, and the larger society simultaneously play a role in population health (Xavier da Silveira dos Santos and Liberali, 2019 ; Antonucci and Webster, 2014 ). In this philosophy, we define health from three levels: cells , selves, and societies . What happens when these levels do not function in cooperation?

When the functioning of cells disrupts the functioning of the self, a state dis-ease in the self can follow. For example, prolonged dysfunction in autoimmune conditions can lead to prolonged dysfunction for the (individual’s sense of) self by triggering depression, decreased motivation, or anxiety (Lougee et al., 2000 ; Garud et al., 2009 ). The reverse can also be true. When the functioning of the self (i.e. one individual) disrupts the functioning of their cells, a state dis-ease in the cells can also follow. For example, prolonged sugar binging and addictive eating can lead to prolonged high blood sugar and pancreatic dysfunction seen in diabetes (De Koning et al., 2011 ; Imamura et al., 2015 ). Cells and selves are not separate.

When the functioning of the self disrupts the functioning of the society we observe a state dis-ease in the society. For example, one person’s unprotected sex with multiple partners can also lead to epidemics and social conflicts. The reverse can also be true. When the functioning of the society disrupts the functioning of the individual, a state dis-ease in the self can follow. For example, dysfunctional social conditions (as seen in Rutter, 1998 ), can lead to prolonged psychological and behavioral dysfunctions of individuals. Selves and societies are not separate.

When the functioning of society disrupts the functioning of cells, a state of dis-ease in the cells can also follow. For example, prolonged dysfunction in society in the form of misguided values about cleanliness, can lead to over-sanitization practices that create superbugs and antibiotic-resistant bacteria (Zaccheo et al., 2017 ; Finkelstein et al., 2014 ; Bower and Daeschel, 1999 ). The reverse can also be true. When the functioning of cells disrupts the functioning of the society, a state of dis-ease in the society can follow. Prolonged dysfunction in cells from naturally occurring parasites (e.g. Yersinia pestis [Cui et al., 2013 ]) can lead to prolonged dysfunctions like the economic collapse following 14th century Black Death (Haensch et al., 2010 ). Cells and societies are not separate.

What does health look like when these levels work together? Recent reports on the Blue Zones (i.e. the areas of the world where populations live significantly longer and healthier than the average) demonstrate that healthy functioning at these levels enhances physical longevity and mental wellbeing in populations (Buettner, 2012 ; Poulain et al., 2013 ). Buettner ( 2012 ) reports on how Blue-Zone populations intentionally and habitually enrich their physical bodies with healthy eating and physical activity. In addition to integrating physical and behavioral practices, these communities also integrate behavioral and social practices, such as, goal-setting, meditations/prayer, social engagement, pursuit of purpose, and community gathering. Humor is used by individuals and groups as a means to practice ease when challenges present themselves (Buettner, 2012 ). Blue Zone communities place value upon physical/natural, behavioral and social processes, generating them intentionally and habitually.

Both states of ease and dis-ease can teach us about the contributions of cells, selves, and societies to population health. Although it is important to be able to observe the levels separately to describe their contributions, it is also important to consider how the levels integrate to impact healthy publics. We acknowledge that meaningful changes can be observed above and below these levels (e.g. at the level of the biosphere and genome). However, this initial paper will introduce levels that are most proximal and accessible to the experience of a general readership (Fig. 1 ).

Principle 3: Health emerges from systems whose primary purpose is to generate maintainable-ease of functioning at a respective level

We propose that systems exist at each level with the purpose of generating maintainable-ease of functioning at that level. The biological immune system, an individual’s system of health behaviors, and the social system will be observed as systems that generate maintainable-ease of functioning in cells, selves, and societies respectively (Fig. 2 ).

Principle 3a: The biological immune system is directly responsible for maintainable-ease of functioning at the level of the cell

Throughout the course of human evolution, the complexity and biodiversity of the human body continued to increase (Rodríguez et al., 2012 ). What keeps the trillions of cells and microorganisms in cooperation in a human body? The biological immune system maintains functional cells (Rodríguez et al., 2012 ). Although it is documented that the functioning of the biological immune system has implications for behavioral functioning (Ader, 1974 , 2000 ; Johnston et al., 1992 ; CDC, 2016 ) and social functioning (CDC, 2016 ; Reidel, 2005 ; Cutler and Miller, 2005 ) the system’s primary purpose is supporting functioning in the cellular/biological system.

Principle 3b: Health behavior is directly responsible for maintainable-ease of functioning at the level of the self

Throughout the course of time, the complexity of human behavior, has continued to increase (Boulding and Khalil, 2002 ). What keeps an individual in a state of balance during times of rapid change? One’s system of health behaviors (e.g. one’s practices of breathing, drinking, eating, and moving) maintain a functional self. Although it is well documented that the behavior of the individual impacts biological functioning (Fadel, 2013 , 2015 ) and social functioning (Omer et al., 2009 ), one’s system of health behaviors directly impacts one’s experience of (or one’s ‘sense of’) their “self”.

Principle 3c: The social system is directly responsible for maintainable-ease of functioning at the level of the society

Throughout history, the social diversity of human societies continued to increase. During periods of rapid increases in social diversity and cultural integration, what supported cooperation in the society? Social systems (e.g. public governments, private social organizations, religious/spiritual organizations) emerge to maintain a functional society. Although it is well documented that a social system can impact biological functioning (CDC, 2016 ; Riedel, 2005 ; Cutler and Miller, 2005 ) and behavioral functioning (Buettner, 2012 ), the social system’s primary role is to maintain functions at the level of the society.

Principle 3d: By considering health as maintainable-ease of functioning generated by systems , we have the ability generalize health across levels

To observe health at the level of the cell, the self, and the society simultaneously, we consider systems that support maintainable-ease of biological, behavioral, and social functioning. The biological immune system, an individual’s system of health behaviors, and the social system make meaningful contributions to the functioning of cells, selves, and societies, respectively. While these systems are not the only systems that impact each level (e.g. one’s cardiovascular system impacts cells, one’s “personality” impacts the self, the environment impacts society), the biological immune system, health behavior, and the social system have great implications for population health from their respective levels; and they can be operationalized at these levels based upon their functions .

By considering health as maintainable-ease of functioning (rather than maintained biological structures) at multiple levels, we set a point of reference from which to integrate important determinants of population health. When taking the structuralist’s perspective, the biological immune system, health behavior, and social systems appear as distinctly separated. When taking a functionalist’s perspective, the biological immune system (i.e. the integration of host defense functions and microbiota functions), one’s (system of) health behaviors (i.e. the integration of decision-making/executive functions and habits/habitual life functions), and the social system (i.e. the integration of population values and population behaviors) appear together in A Philosophy of Health.

Principle 4: Each system employs two general functions— variation and precision —to generate maintainable-ease of functioning at a level

The functionalist perspective allows us to observe systems based upon their functions . The biological immune system will be observed as an integration of host defense functions and microbiota functions (Hooper and Littman Macpherson, 2012 ); (2) an individual’s system of health behaviors will be observed as an integration of decisions/executive functions and habits/habitual life functions (de Bruin et al., 2016 ; Verplankern, 2005 ; Norman et al., 1998 ; Prochaska et al., 1994 ; Prochaska et al., 1991 ); and the social system will be observed as an integration of actively functioning values and population-wide behaviors that function in relation to those values (Dowling and Pfeffer, 1975 ; Cotgrove and Duff, 1981 ).

By researching the role of these functions at each level, we distilled two general functions of each system: variation and precision. Variation appears in the functions of each system that generate a range of abilities, the “varied-abilities”, that sustain health in presently changing conditions. The microbiota, habits/habitual life functions and population behaviors will be observed (in Principle 4a) as the variation-functions of the biological immune system, health behavior, and the social system, respectively. Precision appears in those functions that prioritize and organize the patterns of variation that can sustain health at a level in future, changing conditions. The host-defense functions, decision-making/executive functions, and values systems will be observed (in Principle 4b) as the precision-functions in the biological immune system, health behavior, and the social system, respectively.

Consideration of a complementary relationship among precision and variation is not novel. Precision and variation have been discussed as central to the development of neural and biological systems (Hiesinger and Bassem, 2018 ). Discussions of precision and variation have also provided important insight into research on the biological immune system (Albert-Vega et al., 2018 ; Brodin et al., 2015 ). Through this philosophy, one can go beyond biological systems to observe how precision (in the form of host-defense functions, decision-making/executive functions, and values) and variation (in the form of microbiota functions, habits/habitual life functions, and population-wide behaviors) integrate to generate to maintainable-ease of functioning in cells, selves, and societies simultaneously (Fig. 3 ).

Principle 4a: Variation is responsible for generating the range of abilities, the “varied-abilities”, that can express ease-of-functioning in presently changing conditions

Without functional variation, life is fragile because the present environment is always changing (Taleb and Blyth, 2011 ). Fragile systems’ inability to experience changing conditions (in part) relates to limited variability. Conversely, adaptive system’s ability to experience changing conditions (in part) relates to functional variability (Taleb, 2012 ). When one microorganism in the microbiome takes over, biological fragility reflects a state of infection. When one habit takes over, behavioral fragility reflects a state of an addiction/dependence. When one population behavior takes over (e.g. when economic participation or access to food is restricted to a small percentage of the population) social fragility reflects a state of social/civil unrest.

The human microbiota is comprised of trillions of microorganisms, such as bacteria, fungi, and viruses. When variability in the human microbiota exists, an ease of functioning, or “homeostasis” in cells can be expressed in the present biological/ecological environment (Parfrey and Knight, 2012 ; Bogaert et al., 2011 ; Claesson et al., 2011 ). Research demonstrates that variation in the microbiota impacts the health of human cells by metabolizing complex carbohydrates, converting proteins to neural signals, and modulating diurnal rhythms that maintain biological homeostasis (Clemente et al., 2012 ; Rothe and Blaut, 2012 ; Blaut and Clavel, 2007 ; De Vadder et al., 2014 ). When variation in the microbiota is dramatically limited or changed (e.g. following antibiotic overuse), cellular tissue in the human body is fragile and vulnerable to infections, allergies, and inflammatory outbreaks (Francino, 2016 ).

When one’s habitual life functions (e.g. breathing, drinking, eating, and moving) and one’s healthy habits (e.g. one’s weekly exercise schedule, or weekly meal preparation) can be expressed freely, an ease of functioning is felt by one-self in the present environment. When life functions are no longer expressed with ease (e.g. breathing and movement are compromised due to prolonged sedentary lifestyle), or when a single habit takes over one’s lifestyle (e.g. smokes breaks “must” occur every 30 min), an individual is vulnerable to stressful outbreaks and chronic states (Al’Absi, 2011 ; Conrad et al., 2007 ; Suess et al., 1980 ; León and Sheen, 2003 ; Parrott, 1999 ; Koob, 2008 ).

When the basic human rights in a society are preserved in the present (e.g. right to life, freedom of speech; right to property), human populations have the ability to freely engage in the population - wide behaviors (e.g. health behaviors, social behaviors, economic behaviors) that support a functioning society. Health behaviors drive health and longevity. Social behaviors drive communication and cooperation. Economic behaviors drive goods and resources. When these population-wide behaviors are chronically restricted in a population (e.g. poor access to health care, oppression of free-speech, economic crash), societies become vulnerable to social/civil unrest [as commented historically by Victor Frankl ( 1985 ), Alexander Solzhenitsyn ( 2003 ), Franklin D. Roosevelt ( 1941 ), and Dr. Martin Luther King ( 1985 )].

Variation is essential so that a system has varied-abilities that can express ease-of-functioning in present environmental conditions . Dramatic and prolonged restrictions to variation in the microbiota, habits/habitual life functions, and population-wide behaviors characterize fragile and vulnerable states in cells, selves, and societies. Conversely, functional-variation supports resilience, robustness, and antifragility (Taleb, 2012 ). This does not mean that infinite variation is desirable; however, in this philosophy, precision is responsible for organizing expressions of variation so that the system does not degrade into unpredictably random variation or chaos (see Principle 4b).

Principle 4b: Precision is responsible for prioritizing and organizing the patterns of variation that maintain ease-of-functioning in future, changing conditions

Some environmental changes are too challenging for ease to be expressed in the present. However, following an exposure to challenging conditions, some systems adapt and become more functional (Taleb, 2012 ). Without the ability to functionally organize after stressors, a system degrades into disorder or chaos over time. Host-defense functions, decision-making/executive functions and values systems prioritize and organize variation in the microbiota, habits/habitual life functions, and population behaviors respectively.

When a pathogen invades the biological system, precise responses must occur to organize this potentially chaotic situation. At the level of the cell, a functional host-defense system (comprised of the innate, adaptive and complement immune system branches) organizes the biological system so that functional invaders (i.e. symbionts) and healthy cells are maintained and dysfunctional invaders (i.e. pathogens) and damaged cells are removed (Hoeb et al., 2004 ; Janeway, 1992 ; Janeway and Medzhitov, 2002 ; Janeway et al., 2014 ). When precision is dysfunctional, the host-defense system may (1) fail to prioritize responses to a costly invasion, leading to a state of infection; or (2) the host-defense system might prioritize dysfunctional responses to the cells of body that prolong a state of autoimmunity (Naor and Tarcic, 1982 ).

When a bad habit emerges, precise responses must occur to organize this potentially chaotic situation. At the level of the self, functional decision-making (or at smaller scales executive functioning) prioritizes and organizes behavior so that functional expressions of habit (or at smaller scales, habitual life functions) are prioritized regularly, and dysfunctional ones are replaced or minimized (de Bruin et al., 2016 ; Prochaska et al., 1994 ; Prochaska and Prochaska, 2016 ; Prochaska et al., 1988 ; Redding et al., 2011 ; Weissenborn and Duka, 2003 ; Bickel et al., 2012 ). When dysfunctional, decisions may (1) fail to prioritize responses that remove a costly expression of habit (e.g. a teen started smoking cigarettes to “be cool” and now has to smoke in the bathroom before each class to get through the day; by not deciding to move at work, one’s breathing becomes shallow and movement becomes rigid); or decisions may (2) prioritize habits that prolong dysfunction despite knowing the dangerous consequences (e.g. an adult continues smoking cigarettes despite knowing the family’s history of lung cancer; an adolescent continues binge on sugar despite a diabetes diagnosis).

When dangerous population-wide behaviors threaten life in a society, precise responses must occur to organize this potentially chaotic situation. At the level of society, the agreed upon values organize the social system so that functional population behaviors are prioritized and dysfunctional population behaviors are minimized. Functional values prioritize behaviors that support the society (e.g. as seen when societies mandate that students get certain vaccines before attending University), while also setting standards that remove/replace behaviors that threaten the society (e.g. new laws create legal repercussions for risk behaviors in society). Without values that functionally prioritize population-wide behavior, society may (1) fail to prioritize responses to a dysfunctional population behavior (e.g. as seen during AIDS epidemic of the 1980s due to insufficient public health values around safe sex); or society may (2) prioritize dangerous behaviors that can prolong societal dysfunction (e.g. the antibiotic resistance crisis (Ventola, 2015 ; Michael et al., 2014 ) has been attributed in part to the over-valuing or over-use of antibiotic medications in healthcare practices).

Precision is essential so that a system can maintain ease-of-functioning in future, changing conditions . When precision does not adequately detect the presence of costly conditions, a response may not be prioritized (e.g. as seen during acute infection, addiction/dependence following a surgery, the AIDs outbreak in the 1980s). When precision prioritizes responses that prevent ease longitudinally, dysfunction is prolonged (e.g. autoimmunity, continued smoking despite family history of cancer, misguided values that create an antibiotic-resistant bacteria). Through dysfunctional -precision, the conditions for life in cells, selves, and societies becomes disordered over time. Through functional -precision, a system prioritizes responses that maintain ease-of-functioning in future conditions. Prioritizing functional microorganisms (i.e. symbionts) supports the developing life of cells; prioritizing functional habits (e.g. weekly exercise) and habitual life functions (e.g. diaphragmatic breathing and relaxed movement) supports the developing life of the self; and prioritizing functional population behaviors (e.g. access to functional health care, economic resources; access to social support) supports the developing life of the society.

Principle 5: Health is valued by a system when precision-and-variation generate maintainable-ease of functioning. Health is de-valued by a system when precision or variation prevent maintainable-ease of functioning

By defining precision-and-variation, we can better understand maintainable-ease of functioning in population health:

Functional-Variation generates ease-of-functioning in the present (e.g. fluid and variable motion reflects an ease and variability of one’s movement); while Functional-Precision prioritizes expressions that can maintain ease-of-functioning in the future (e.g. prioritizing challenging exercise for 20 min each day may lead to an ease in bodily movement long term).

Dysfunctional-Variation prevents ease-of-functioning in the present (e.g. prolonged sitting might lead to rigid movement and shallow breathing); while Dysfunctional-Precision might prioritize expressions that prevent ease in the future (e.g. rather than focus on relaxing breathing and movement on work breaks, one decides to drink alcohol to relax).

Without functional-variation, life is fragile and vulnerable to changing conditions of the present. Without functional-precision, life becomes disorganized from the system’s exposure to changing conditions across time. When functional-and-integrated, precision-and-variation value maintainable-ease of functioning in cells, selves, and societies. When dysfunctional or fragmented, precision or variation can de-value maintainable-ease of functioning in cells, selves, or societies. If maintainable-ease of functioning can be valued in cells, selves, and societies, we will likely observe healthy publics.

Five principles of health are presented: (1) Health is the maintainable-ease of functioning; (2) Maintainable-ease of functioning emerges from multiple levels ; (3) At each level, maintainable-ease of functioning is generated by systems ; (4) Each system employs two functions, precision - and - variation , that generate maintainable-ease of functioning ; and (5) Health is valued by a system if precision-and-variation generate maintainable-ease of functioning. Through these five principles, both naturalistic and holistic perspectives can be considered simultaneously because maintainable-ease of functioning is relevant to biological functioning (e.g. as described in BST) and personal/social, goal-oriented functioning (e.g. as described in HTH). This philosophy can also be used to investigate how naturalistic and holistic phenomena have informed past healthcare interventions. What do vaccine interventions, behavior change interventions, and social change interventions have in common? When successful, these interventions enhance both precision and variation.

Vaccine interventions can enhance both the precision of the host-defense functions and variation in the microbiome. During a vaccine intervention, the microbiome is exposed to a new variation in the form of a new virus (Reidel, 2005 ). Through this exposure, the precision of host defense functions can adapt to prioritize maintainable-ease of functioning in the microbiome in the future. How? The host-defense system produces antibodies that allow the immune system to respond effectively and efficiently to this virus when exposed to it again in the future (Janeyway, 2014 ). Although the precision of the immune system has been enhanced to handle historical threats through vaccines (e.g. for small pox, chickenpox, measles), new viruses like the coronavirus can still emerge. With this philosophy, vaccine developers and public health officials might not only ask the question, “How do we combat the coronavirus?” Researchers, vaccine developers and public health officials may also ask the functional question: “How do we enhance the precision of the host-defense system and the variation of the human microbiome to adapt following an exposure to the coronavirus?”

Behavior change interventions can enhance both the precision in one’s decisions and the variation in one’s habits. During a behavior change intervention, a person’s existing habits are exposed to a new variation in habit. For example, the beginning of a new exercise intervention exposes the individual’s current habits/habitual functioning to changes in movement and breathing (i.e. exercise) that may also change their patterns of eating and hydration. Through this exposure, a person’s decision-making might adapt to prioritize maintainable-ease of functioning in the individual’s lifestyle. How? Some behavior change interventions train one’s decision-making to remove or “counter-condition” unhealthy habits, by replacing them with healthy habits (Prochaska et al., 1988 ). Although modern behavior change interventions have shaped the precision of decision-making during health behavior change (e.g. of smoking, diet, alcohol use, inactivity), new problems for health behavior still emerge when the individual is exposed to a new, potentially addictive technology. With this philosophy, behavior change interventionists and health officials might not only ask the question, “How do we support good decision-making of individuals?” Researchers, behavior change technology developers, and public health officials may also ask the functional question: “How do we enhance the precision of one’s decisions and the variation of one’s habits following the exposure to a new, potentially addictive technology?”

Public health campaigns disseminated by social organizations can enhance the precision of the population’s health values and variation in population-wide health behaviors. Leading up to first Surgeon General’s Advisory Committee on Smoking and Health (1964), the U.S. Department of Health had become increasingly aware of (i.e. exposed to) variations in a population health behavior. If populations smoked, then populations were more likely to develop lung cancer, laryngeal cancer, or chronic bronchitis (CDC, 2018 ). Following this exposure to (the consequences of) population smoking behavior, society’s values shifted to prioritize health. How? The Federal Cigarette Labeling and Advertising Act of 1965 was adopted, and the Public Health Cigarette Smoking Act of 1969 was adopted to create new health values. This shift in values prioritized new variations in population health behavior by: (1) requiring a health warning on cigarette packages; (2) banning cigarette advertising in the broadcasting media; and (3) calling for an annual report on the health consequences of smoking (CDC, 2018 ). Since these first initiatives adult smoking rates have fallen from about 43% (in 1965) to about 18% today; and mortality rates from lung cancer, the leading cause of cancer death, are declining (Department of Health and Human Services, 2014 ). Although the precision of the population’s values has been enhanced to impact population behaviors (e.g. the tobacco laws described above supported healthy change), new chronic states can still emerge following exposure to social changes (e.g. the invention of the Juul impacted high school and college aged populations). With this philosophy, public policy officials and public health researchers might not only ask the question, “How do we create new laws to protect population health from nicotine addiction?” They may also ask the functional question: “How do we enhance the precision of the population’s values and the variation of the population’s behavior following the invention of a new nicotine delivery system technology (e.g. flavored Juuls)?”

Previously we described that without functional variation, life is fragile when exposed to present changing conditions; and without functional precision, life becomes disorganized from exposure to changing conditions across time. When successful, the above interventions upon biological, behavioral, and social functioning have a common theme: each facilitates exposures to biological, behavioral or social conditions that support (1) increasingly complex/diverse variation; and (2) increasingly organizable precision. Exposure, not avoidance , has facilitated population health in these interventions. While healthcare systematically prioritizes biological exposures in the form of vaccine interventions, they do not systematically prioritize behavioral or social exposures. However, it is documented that exposure to healthy behaviors in youth prevents risk behaviors in adolescence (Velicer et al., 2000 ); and exposure to community-based health initiatives can support population health (Dulin et al., 2018 ; CDC, 2018 ). Given that systematic biological exposures in the form of vaccination have led to a global control of some acute infectious diseases (Tangermann et al., 2007 ); might systematic behavioral and social exposures (especially in youth) be needed to enhance global campaigns toward the control of chronic disease?

A functional language of health is central to the success of a Philosophy of Health. Why? The levels are not separate, but rather are continuously connecting with one another. A good philosophy of health should have the ability to discuss assessment, diagnosis, intervention, and prevention across levels, across systems, across cultural populations, and across time. Using the common language of precision and variation creates discussions that connect the levels and integrate research disciplines.

A case (to) study: mental health as between-level functioning in this philosophy

Historically, and still too often, health professionals have an expertise at one level, that limits their prescription of interventions to that level. This can actually create barriers to a complete solution when a health problem is multileveled. While a person’s mental health is typically assessed based upon their first-person experience of thoughts, feelings, and behaviors; symptoms can be triggered by biological, physiological, behavioral, psychological, and/or social dysfunction. Most clinicians typically do not have the ability to assess and address all forms functioning. So if one person, John, is meeting with a clinician who specializes in primary care medicine, he may only be prescribed a biological intervention like medication. If John is meeting with a clinician who specializes in behavioral medicine, he may only be prescribed a health behavior change intervention. If John is meeting with a clinician who specializes in a certain theory of psychotherapy, he may only be prescribed a psychotherapy intervention based on the clinician’s training. If John is meeting with a clinician who specializes in social work, he may only be prescribed a group, community or social intervention. While the above specializations have been helpful in establishing an empirical bases for mental health interventions, over-specialization can be problematic when a multi-leveled solution is needed. In addition, it can also be problematic when a level-specific solution is needed that the clinician cannot provide (e.g. when psychotherapy is needed but a clinician only has the ability to prescribe psychiatric medication).

Technology poses a multileveled issue for population mental health in 2020. Selves have more social connection then ever in history, yet societies are characterized by increasing rates of depression and loneliness (Sum et al., 2008 ; Hammond, 2020 ; Srivastava and Tiwari, 2013 ; Twenge, 2017 ). Researchers might use this Philosophy of Health to facilitate between-level conversations that address seemingly paradoxical outcomes that emerge during this new age of rapid technological growth. To do this, a researcher might first begin by asking questions about functioning at each level ; second , ask questions about processes between the levels ; and third , concurrently ask questions at and between levels .

First: Begin by asking questions at each level

Novel challenges face the iGeneration (and their parents) due to technology’s novel impacts on the development of individual and social functioning (Twenge, 2017 ). For example, if John’s decisions (self-precision) and habits (self-variation) remain consistent during school hours because his parents do not let him have a phone; but his class’ social behaviors around him (society-variation) change dramatically because everyone else at school uses the newest smartphone application to talk during class; will John’s mental health suffer? Although his parents’ intentions are to protect John, the contrast between his behavior (self’s precision-and-variation) and the population social behavior (society-variation) can impact John’s health. Notice here how we have not yet considered functions that connect the self to the society (e.g. John’s thoughts and feelings). Rather we first consider (or contrast) functioning at the level of the self (i.e. John’s decisions-and-habits) and the society (i.e. population social behavior) in accordance with Principles 1–5 (see Figs 1 – 3 ).

Second: Look for functional processes that connect the levels

One person’s thoughts and emotions/feelings are processes that help to integrate the functioning of one-self within the functioning of a society. How might John’s thoughts and feelings connect his (sense of) self to his society? Perhaps John’s parents teach him that it is important to feel separate from his classmates during class so he can think clearly in class; and that he can feel connected to his friends by inviting them over to communicate together after school. This parenting may impact John’s thoughts and feelings during school. If John’s parents do not talk with him about this topic, John may experience different thoughts and feelings during school hours. When kept to one-self, thoughts and emotions are foundational to an internal sense of self as one functions in the larger society; and, when acted upon, thoughts and feelings can become verbal communication (e.g. speech) and non-verbal communication (e.g. body language, facial expressions) that form an external sense of self that is visible to the society. The (internal) experience of and (external) communication of thoughts, feelings and actions form the foundation of all systems of psychotherapy (Prochaska and Norcross, 2018 ). This view can be particularly helpful as researchers begin to investigate how smart technology impacts developmental changes to the self within the society beginning in youth.

Third: Concurrently ask questions at and between levels

Perhaps, a clinical researcher is interested in investigating protective mental health factors in the iGeneration; and they hypothesize that lower rates of loneliness, anxiety, and depression will be seen in subjects that do not respond to text messages immediately. The researcher might investigate further by using the philosophy to develop questions for the research subjects: “(1) Do you use conscious decision-making (self-precision) to prevent yourself from habitually responding to your phone when a text appears (self-variation)? (2) How fast do other’s in your social group typically respond to texts (society-variation)? (3) What changes in thoughts and feelings are experienced (internal self-society connection) after you communicate via text (external self-society connection)?” Perhaps this researcher also wants to investigate how those who are addicted to the technology perceive non-responders. The clinical researcher might again apply the philosophy: “(1) How fast do other’s in your social group typically respond to your texts (society-variation)? (2) Do you experience changes in thought and feeling (internal self-society connection) when others do not respond to you within an hour (society-variation)? (3) How do you communicate those thoughts and feelings (external self-society connection) with others when they do not respond for a prolonged period of time (society-variation)?” Future research might use this method to gather and organize levels of information on mental health factors across different self- and societal-conditions.

The processes that form our mental health form a functional connection between self and society. If mental health is a reflection of the self–society connection, what might be a reflection of the self–cell connection? Physiological health evidences a functional connection between our sense of self and our cells. For example, aerobic exercise is a health behavior that stimulates changes to variations in breathing and movement. By engaging in this behavior, the biological cells of the body are also stimulated via various physiological processes. Breathing will stimulate cellular functioning via the cardiovascular and respiratory systems; and movement will stimulate cellular functioning via the cardiovascular, musculoskeletal, and central nervous systems. While all physiological systems are working in collaboration in the body, certain changes to behavioral and biological functioning will stimulate certain physiological systems. By viewing health through this lens, between-level observations join the philosophy: biological functions emerge at the level of the cell; physiological functioning emerges as the cell–self connection; behavioral functions emerge at the level of the self; psychological/mental functioning emerges as the self–society connection; and social functions emerge at the level of the society. Future papers will explore maintainable-ease of functioning at and between levels.

Future directions: new images of healthcare integration and new perspectives of healthcare innovation

By considering this integrative philosophy, one can define health based upon a tangible connectedness, rather than separateness, of cells, selves, and societies. We provide Image 4 as a way to visualize the common paths to the health of healthy publics. When researchers observe that a host defense system is changing cellular functions following an infection, they may also expect these changes to have an impact [along Path 1] on expressions of habitual or physiological functions (e.g. immune function can stimulate the sensation of “achiness” or “pain” altering one’s physical movement, breath rate, hydration, and hunger) (Kelley, 2003 ; Johnson et al., 1992 ; Danzer, 2009 ). When researchers observe an individual deciding to engage in health behavior change following an addiction, they may also expect these changes to have an impact [along Path 2] on the group-behavior of their family system or social systems. When researchers observe changes to society’s values following a newly detected problem (e.g. laws ban Cigarette Advertising in broadcasting media; public health standards mandate certain vaccines before attending school), they may also expect that these changes can have an impact on behavioral functions of individuals [along Path 2] and biological functions of cells/organs [along Path 3]. These levels are continually integrating along these common paths to the health of healthy publics (Fig. 4 ).

When attending to this connectedness new, important questions can have new answers. What function does modern technology serve in population health and healthcare? If technology algorithms prioritize variations in population behaviors, then they fulfill a role as society-level precision. When modern technologies like machine learning (ML) technology and Computer Tailored Interventions (CTI) prioritize patterns of population behavior, we can see profound impacts on social change in a society. Although one might argue that technologies can be used by individual-level functions, the algorithms that are currently deployed and updated on devices interface with big-data gathered on population behaviors (Manogaran and Lopez, 2017 ; Dinov, 2016 ; Mullainathan and Spiess, 2017 ; Cheng et al., 2017 ).

In this paper, we identified that precision can be functional or dysfunctional. Similarly, technologies can support or prevent healthy population behavior. Some technologies prioritize health behavior in populations by tracking physical activity and providing feedback on activity progress; while others prevent healthy behavior by prioritizing sedentary behavior through video-gaming. Some social media technologies facilitate social communication with distant friends and relatives that supports wellbeing; while others facilitate conflictual communication that diminishes wellbeing. Given that modern technology can support or hinder health, we believe it is important that healthcare can prioritize technological innovations that value health in cells, selves, and societies. To do this, technology innovators might seek to value a higher order construct (e.g. maintainable-ease of functioning) in their algorithms.

Medical technology is currently used to titrate the doses of vaccines so that maintainable-ease of biological functioning (i.e. inoculation) is made available to the general population. When biological exposures are not properly titrated, infections can become active in the population and health is no longer valued at the level of the cell. Similarly, when behavioral and social exposures are not tailored to the needs of individuals and groups, populations can become resistant to healthy change, and health is no longer valued at the level of the self and the society. Behavior change researchers Prochaska and Prochaska ( 2016 ) report that when individuals and populations are not ready for a change, interventions that force individuals or populations to take action can increase resistance and prolong dysfunction. By tailoring (or what they term “staging”) behavioral and social level interventions, Computer Tailored Interventions upon behavioral and social functioning are made possible (Prochaska et al., 2001 ; Velicer et al., 2000 , Prochaska and Prochaska, 2016 ). Despite these advances, there remains a need for technological advances that can make maintainable-ease of behavioral and social functioning available to the general population.

Future healthcare interventions could benefit from ML algorithms that tailor behavioral and social exposures to enhance precision-and-variation. Research already demonstrates that tailoring interventions for biological precision (Albert-Vega et al., 2018 ) and biological variation (Brodin et al., 2015 ) can impact long-term biological functioning. Future innovations might seek to use technology to tailor behavioral and social interventions to generate maintainable-ease of functioning. Through the functional language used in this paper we hope readers are inspired to present new questions, new comments, and new perspectives about needed healthcare innovations.

This philosophy of health investigates three levels of health: cell, self, and society. The level of the cell accounts for biological functioning within human beings. The level of the self accounts for first-person functioning of each human being. The level of the society accounts for group functioning of human beings.

Each system is responsible for generating maintainable-ease of functioning at a level. The biological immune system is responsible at the level of the cell. A human's system of health behaviors is responsible at the level of the self. The social system is responsible at the level of the society.

Maintainable-ease of functioning is generated by two functions in each system: precision and variation. The human microbiota, habits, and population-wide behaviors evidence variation in cells, selves and societies respectively. The host defense system, decisions, and values evidence precision in cells, selves and societies respectively.

Population health is generated along common paths that integrate the levels. The biological functioing of cells impacts fluctuations of habits/habitual functioning; and vice versa. The behavioral functioning of each self impacts fluctuations in population behavior; and vice versa. The biological functioning of cells also can impact fluctations in population behavior; and vice versa.

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This research was supported by funding from the National Institutes of Health’s (NIH) National Cancer Institute (NCI).

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Saad, J.M., Prochaska, J.O. A philosophy of health: life as reality, health as a universal value. Palgrave Commun 6 , 45 (2020). https://doi.org/10.1057/s41599-020-0420-9

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• Volume 26, Issue 1
• Disease, illness, sickness, health, healing and wholeness: exploring some elusive concepts
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• Kenneth M Boyd
• Edinburgh University Medical School and The Institute of Medical Ethics

Concepts such as disease and health can be difficult to define precisely. Part of the reason for this is that they embody value judgments and are rooted in metaphor. The precise meaning of terms like health, healing and wholeness is likely to remain elusive, because the disconcerting openness of the outlook gained from experience alone resists the reduction of first-person judgments (including those of religion) to third-person explanations (including those of science).

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Introduction

In this paper, I want to explore possible meanings of a cluster of words—disease, illness, sickness, health, healing and wholeness. Many people have tried to elucidate what these words mean, but agreed definitions are often elusive. In what follows I shall begin with some definitions of disease, illness and sickness. I shall then try to say why definitions of disease and health are so elusive; and I shall end with some observations on science and religion, in the light of which the difficulty of defining health, healing and wholeness may make some kind of sense.

Dictionary definitions

Dis-ease (from old French and ultimately Latin) is literally the absence of ease or elbow room. The basic idea is of an impediment to free movement. But nowadays the word is more commonly used without a hyphen to refer to a “disorder of structure or function in an animal or plant of such a degree as to produce or threaten to produce detectable illness or disorder”—or again, more narrowly, to “a definable variety of such a disorder, usually with specific signs or symptoms or affecting a specific location”. That at least is how the New Shorter Oxford Dictionary 1 defines it, adding as synonyms: “(an) illness”, “(a) sickness”. Let me stay with the dictionary to see what it says about those synonyms.

Illness has three definitions. Two of them are of the way the word was used up to the 18th century—to mean either “wickedness, depravity, immorality”, or “unpleasantness, disagreeableness, hurtfulness”. These older meanings reflect the fact that the word “ill” is a contracted form of “evil”. The third meaning, dating from the 17th century, is the modern one: “Ill health; the state of being ill”. The dictionary defines “ill” in this third sense as “a disease, a sickness”. Looking up “sickness” we find “The condition of being sick or ill; illness, ill health”; and under “sick” (a Germanic word whose ultimate origin is unknown, but may be onomatopoeic) we find “affected by illness, unwell, ailing … not in a healthy state”, and, of course, “having an inclination to vomit”.

There is a rather unhelpful circularity about these dictionary definitions. But dictionaries of the English language usually only aim to tell us the origins of words and how they have been used historically. They do not aim at the much more contestable goal of conceptual clarity. For that we have to look elsewhere. In this case, let us look at how disease, illness and sickness have been elucidated first by a medical practitioner, who ought to know something about the subject; and then, after noting some popular and literary definitions, by a philosopher, who ought to know something about conceptual clarity.

A medical definition

Professor Marshall Marinker, a general practitioner, suggested over twenty years ago a helpful way of distinguishing between disease, illness and sickness. He characterises these “three modes of unhealth’”as follows.

“ Disease … is a pathological process, most often physical as in throat infection, or cancer of the bronchus, sometimes undetermined in origin, as in schizophrenia. The quality which identifies disease is some deviation from a biological norm. There is an objectivity about disease which doctors are able to see, touch, measure, smell. Diseases are valued as the central facts in the medical view…

“Illness … is a feeling, an experience of unhealth which is entirely personal, interior to the person of the patient. Often it accompanies disease, but the disease may be undeclared, as in the early stages of cancer or tuberculosis or diabetes. Sometimes illness exists where no disease can be found. Traditional medical education has made the deafening silence of illness-in-the-absence-of-disease unbearable to the clinician. The patient can offer the doctor nothing to satisfy his senses…

“ Sickness … is the external and public mode of unhealth. Sickness is a social role, a status, a negotiated position in the world, a bargain struck between the person henceforward called ‘sick’, and a society which is prepared to recognise and sustain him. The security of this role depends on a number of factors, not least the possession of that much treasured gift, the disease. Sickness based on illness alone is a most uncertain status. But even the possession of disease does not guarantee equity in sickness. Those with a chronic disease are much less secure than those with an acute one; those with a psychiatric disease than those with a surgical one … . Best is an acute physical disease in a young man quickly determined by recovery or death—either will do, both are equally regarded.” 2

Disease then, is the pathological process, deviation from a biological norm. Illness is the patient's experience of ill health, sometimes when no disease can be found. Sickness is the role negotiated with society. Marinker goes on to observe that a sizeable minority of patients who regularly consult general practitioners, particularly for repeat prescriptions, suffer from none of these modes of ill health. They appear, rather, to be seeking “to establish a healing relationship with another who articulates society's willingness and capability to help”. So a “patient”, in the sense of someone actively consulting a doctor rather than just being on the books, does not necessarily mean someone who has a disease, feels ill, or is recognised to be sick; and of course there are other more mundane reasons, short of wanting to establish a healing relationship, why a patient may consult a doctor—to be vaccinated before travelling abroad for example. Most patients most of the time however, probably can be classified as having a disease, or feeling ill, or being recognised as sick.

Popular and literary definitions

For some patients, the last of these may be the most important. Recently I was handing out to a class of medical students the General Medical Council's booklets on The Duties of a Doctor. The university janitor who was helping me unpack them remarked: “As far as I'm concerned the main duty of a doctor is to give me a sick note, otherwise I won't get sick pay”. A week later, on a train, I met a recently unemployed man who recounted to me at some length how he had cajoled his general practitioner into signing him off for a few months longer, so that he could keep on getting sick pay until he got to pensionable age. And according to Hystories , by the American critic Elaine Showalter, 3 new ways of getting recognised as sick are being found all the time. Modern culture is continually spawning hysterical epidemics—in the pre-millennial years, ME, Gulf war syndrome, recovered memory, multiple personality syndrome, satanic abuse and alien abduction. These, a sympathetic reviewer of the book explained, were examples of:

“the conversion of emotional pain and conflict into the camouflaged but culturally acceptable language of body illness… . Typically, individuals who are unhappy or unfulfilled in their lives develop diffuse and evolving nervous complaints and eventually seek help. A physician, or some other scientific authority figure, concocts ‘a unified field theory providing a clear and coherent explanation for the confusing symptoms’, as well as a new and a memorable name for the sydrome. This explanation draws on contemporary disease theory, usually viral and immunological ideas. An individual case or two, often involving a well-known public personality, provides a popular paradigm for the new synthesis of symptoms. A best selling novel …, soon to become a major motion picture, first advertises the syndrome to a large audience. Magazine stories and television documentaries further publicise the symptoms. High-profile books for persons seeking information appear, as do patients' autobiographies. Most recently, daily talk-shows, those agencies of mass pop psychotherapy, unite sufferers and therapists in order to dramatise their life stories and to explain the meaning of their disorder for millions; in the process, participants cite enormous projected numbers of the afflicted and encourage others to come forward… . These are acutely communicable diseases… .” 4

So the reviewer, expounding Showalter, claims. People with ME and Gulf war veterans, by contrast, understandably might contest this view of what they are suffering from; and more scientific findings about the veterans' health 5 have appeared since Hystories was published in 1997. Showalter's argument nevertheless helps to illustrate Marinker's useful distinction between disease, illness and sickness. Whether or not someone is ill, is something the person concerned ultimately must decide for him- or her-self. But whether that person has a disease or is sick is something doctors and others may dispute.

Munchausen's syndrome

Some diseases, clearly, are less respectable than others. A classic example is Munchausen's syndrome, the diagnostic label applied to people who repeatedly present themselves to hospitals with convincing symptoms, often demanding and sometimes undergoing surgery which reveals no organic disorder. People with Munchausen's syndrome may seem reminiscent of Marinker's repeat prescription patients who seek “a healing relationship with another who articulates society's willingness and capability to help”. But their condition is more likely to be dismissed as “a bizarre form of malingering” 6 or “the systematic practice of deliberate and calculated simulation of disease so as to obtain attention, status and free accommodation and board”. 7 Most of them, it may be explained, “are suffering from psychopathic personality or personality defect”, a condition defined as being “characterised by impulsive, egocentric and antisocial behaviour”, with “a difficulty in forming normal relationships, and a manner which is either aggressive or charming or which alternates between the two”. 8 That, it might be observed, makes them sound suspiciously like people who have not had the opportunity or luck to end up as successful politicians or captains of industry.

People labelled with Munchausen's syndrome then, may have succeeded in getting recognised as being sick, but not in the sense they intended. In Marinker's terms, their sickness has pretty low status. It is doubtfully a disease, and as illness its meaning veers more towards the pre- than post-18th century usage—“wickedness, depravity, immorality”. Such words, or the colloquial “sick, sick, sick”, are even more likely, of course, to be applied to the perpetrators of Munchausen syndrome by proxy—people who abuse a child or frail elderly relative by making them ill or pretending that they are ill.

Philosophers' questions

Are such people mad, or bad? How do you answer such a question? To try to find a more helpful way of framing it, let me move on to the purveyors of conceptual clarity, the philosophers. To doctors, Marinker suggests, disease is the most tangible mode of unhealth. When they talk about disease, they know what they mean. Philosophers are less sure. R M Hare, for example, asks:

“Why do attacks of viruses count as diseases, but not the attacks of larger animals or of motor vehicles? Is it just a question of size? Or of invisibility? I believe that doctors call the attacks of intestinal and other worms diseases, though there are also more precise words like ‘infestation’. If I have a tape or a guinea worm (which are quite large), do I have a disease? Does it make a difference if the worm can be seen but its eggs cannot? Or does it make a difference that the worm, although it can eventually be seen, is in some sense, while active, inside the patient, whereas dogs and lorries, and also lice and fleas, whose attacks are likewise not called diseases, are always outside the body? Does a disease have to be something in me? And in what sense of ‘in’? Some skin diseases such as scabies are so called, although the organisms which cause them are on the surface of the skin, and do not penetrate the body. They penetrate the skin indeed; but then so does the ichneumon maggot, and the body too. Is the difference between these maggots and the scabies mite merely one of size? Or of visibility?” 9

Well perhaps, Hare suggests, we just use the word “disease” for “conditions whose cause was not visible before the invention of microscopes”. But a more basic point, he adds, is that “in order to identify a condition as a disease we … have to commit ourselves to there being a cause, ascertainable in principle, of the same sort as the causes of diseases whose aetiology we do understand”. What I take Hare to mean by this, is that when doctors apply a diagnostic label like Munchausen's syndrome, for example, they are committing themselves to the hope that someday they will be able to understand—in medical terms (“mentally ill” or “mad”), rather than moral ones (“bad”)—what makes these people act in the way they do.

But what does “understand in medical terms” mean in this context? Does it mean that doctors hope to find some causative agent in the patient, or in the patient's environment? Or does it just mean that they are robustly rejecting Kant's demand “that all the insane be turned over to the philosophers and that the medical men stop mixing into the business of the human mind” 10 — in the vague hope that a therapeutic approach will eventually prove to be more effective than a moral or legal one? And what are we to make of the fact that doctors have chosen to label Munchausen's syndrome by the name of a fictional liar, rather than by the name of the distinguished psychiatrist who first identified it, or by some medical term which suggests the direction in which they are looking for an explanation? Applying the disease label to this, and maybe some other conditions, sounds not very different from what St Anselm called fides quaerens intellectum , “faith seeking understanding”—although in this case the doctors sound rather less optimistic about finding a cause than St Anselm was about proving the existence of God.

At this point, of course, doctors might protest that theorising around an example like Munchausen's syndrome is more typical of philosophy than of more everyday medical practice, in which medical faith, seeking understanding, has repeatedly found it. I think that response is fair. But to be fair to philosophers too, let me add that Hare is not arguing that “disease” is a kind of linguistic weapon wielded by doctors in order to get patients to submit to them. His point rather is that the word “disease” has an evaluative character. Using it can be justified, if patients and doctors evaluate it in the same way—if patients agree with their doctors that the disease is bad for them. But it becomes problematic when this agreement is absent. This suggests one reason then, why definitions of disease can be so elusive. To call something a disease is a value judgment, relatively unproblematic in cases when it is widely shared, but more contentious when people disagree about it.

When philosophers try to define health some of them reach a similar conclusion. R S Downie for example, agrees that the World Health Organisation definition of health—as “a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity”—is overambitious. Nevertheless, he argues, it is probably aiming in the right direction. 11 To try to define health as simply the absence of disease or infirmity leads you into difficulties: ill health can't be defined simply in terms of disease, for example, because people can have a disease (especially one with minor symptoms) without feeling ill, and they can have unwanted symptoms (nausea, faintness, headaches and so on) when no disease or disorder seems to be present. Nor is the fact that a condition is unwanted enough to describe it as ill health: it may be the normal infirmity of old age for example; and again a condition's abnormality is not enough either—a disability or deformity may be abnormal, but the person who has it may not be unhealthy; and much the same may apply to someone who has had an injury. To say whether or not physical ill health is present therefore, a complex combination of “abnormal, unwanted or incapacitating states of a biological system may have to be taken into account”. And things are even more complicated when assessing mental ill health. Abnormal states of mind may reflect minority, immoral or illegal desires which are not sick desires. On the other hand, a psychopath, for example, may neither regard his state as unwanted, nor experience it as incapacitating.

The problem, however, is not just that ill health can be difficult to pin down. It is also that we normally think of health as having a positive as well as a negative dimension. But here again things are complicated. A positive feeling of wellbeing, for example, may not be enough. As Downie says: “it would be difficult to make a case for viewing an acute schizophrenic state with mood elevation and a blissful lack of insight as one of positive health”. Nor is fitness sufficient: the kind of fitness sought in athletic training, indeed, is sometimes detrimental to physical health; and the desire to maximise physical fitness as an end in itself may become an unhealthy obsession. Often, what is required is only a “minimalist” notion of fitness, age-related and geared to everyday activities.

“True” wellbeing, Downie goes on to suggest, requires (a) an “essential reference to some conception of the ‘good life’ for a human being” and (b) “some conception of having a measure of control over one's life, including its social and political dimensions”. Those factors, as well as the complex negative side, have to be taken into account when we ask what “health” means. But even when we have taken all these factors into account, we cannot quantify how healthy an individual is with any precision. That is not just because the sum is complex. It is also, Downie concludes, agreeing with Hare, because the components include value judgments.

Value judgments and metaphors

One reason then, why definitions of disease and health are sometimes so frustratingly elusive is the part played by value judgments in determining what we mean by disease and health as well as what we mean by illness and sickness. In many cases this is not obvious, because most people, in our society at least, make the same or similar value judgments about what these words mean and what are examples of what they mean. There is, as it were, a common core of ideas about what disease is or what health is. But beyond that common core, judgments on whether a condition is a disease, or on what or who is healthy, begin to diverge, and our conceptions of disease and health begin to get fuzzy.

Another way of understanding this, I think, has to do with the important part played by metaphor in the development of thought and language. When we want to talk about some new experience or discovery for which our existing terminology has no adequate resources, a metaphor—a word or words from some other area of experience, but used in a new way—may help us to say what we mean. Some thinkers, for example Nietzsche, and before him Shelley and Coleridge, have argued that all language develops by metaphorising and by metaphors becoming accepted as “literal”. Our language, they say, is littered with “dead metaphors”; and this includes our scientific language. My own favourite example of the role played by creative metaphorising in science is one which I once copied into a notebook from an article about the brain in (I think) the Scientific American :

“Axons sprout new endings when their neighbours become silent and the terminal branches of dendritic arbors are constantly remodeled.”

I find those metaphors drawn from arboriculture to neurophysiology, not only profoundly encouraging, given my own aging brain, but also poetically inspired.

Health as a metaphor

In the case of disease, I have already indicated how metaphorising seems to have been at work, in the development of this more specific term as a particular instance of something causing dis-ease and making for lack of elbow room or freedom of movement. Health as a metaphor may be more complex. The word derives from an old Germanic root meaning wholeness. But the most influential example, in the metaphorising process, of the idea of wholeness, may have been that of the breeding animal at the peak of its performance. If that is right, it may be part of the reason why, as the anthropologist Edmund Leach suggests, “subliminally the general public's idea of good health is all mixed up with ideas about sexual vigour”; and why, despite

“the obvious discrepancy from reality, the model of ideal good health which ordinary members of the public pick up, through the visual images of the Press and the TV screen, and from the verbal suggestions of their doctors, is closely related to the classical ideal of the youthful Greek athlete.” 12

A further point perhaps worth noting here, is that once metaphors get going, they can be hard to stop. Humans are highly imitative animals. During the last general election for example, I noticed the habit of using the word “Look…” as a punchy introduction to a line of often oversimplified argument, spread first among radio interviewers and then to politicians, including eventually Tony Blair. It was, I felt, a rather irritating habit. But after a symposium I took part in soon after the election, I realised that not only had one of the other speakers used “Look…” in the same way, but so had I. Our imitative or mimetic tendency then, may be one of the reasons why successful metaphors tend to proliferate so successfully.

Spiritual health

In the case of “health”, we can see this happening as the metaphor expands from bodily health, to include spiritual health (the Anglican prayer book's phrase, “there is no health in us”), then political health (Shakespeare's Hamlet refers to the “safety and health of the whole state”), and finally to ordinary usage today when we refer to someone having a healthy or unhealthy attitude and so forth.

Now none of this, perhaps, causes much trouble if we understand that these are metaphors when we use them to orientate our thought and action. In many cases moreover, expanding metaphors usually only modify rather than radically alter thought or action already also oriented by other powerful metaphors. For example, to call an accountant a “company doctor” doesn't excuse his “doctoring the books” when an authority holds an “accountant” “accountable”. But problems may arise when a metaphor expands in a sphere where it is not challenged or complemented by other equally powerful metaphors which are also expanding. In that case the metaphor in question may go on expanding its application almost indefinitely.

Something like this, I think, has happened in the case of “health”, as a result of the declining vitality of religious metaphors in Western, or at least European, public discourse. Metaphorical ideals such as “healthy behaviour” and “mental health”, propounded by doctors and others who are perceived to be “objective” and to have no ideological axe to grind, have expanded to fill the vacuum as it were. The absence of any metaphors more convincing than therapeutic ones, thus may help to explain why applying even such a label as “Munchausen's syndrome” seems to many people the best hope of understanding that morally ambiguous condition. Similar reasons perhaps may also help to explain why the language of ethics, again perceived as “more objective” than that of religion, now plays an increasingly important role in Western public discourse. One difficulty about this perception of ethics however, is that it encourages the expectation that ethics should be able to deliver definitive “answers”—just as the public rhetoric of health encourages the expectation that health is something that it ought to be possible, not only to define, but also to achieve.

No health as such

“A medical man”, Sir William Jenner once remarked 13 “needs three things. He must be honest, he must be dogmatic and he must be kind”. A philosopher, by contrast, needs only the first of these. One of the most relentlessly honest philosophers was Nietzsche. Let me quote something he once wrote about health, to echo rather more forcefully what I have been trying to say so far:

“there is no health as such, and all attempts to define anything in that way have been miserable failures. Even the determination of what health means for your body depends on your goal, your horizon, your energies, your drives, your errors, and above all on the ideals and phantasms of your soul. Thus there are innumerable healths of the body; and … the more we put aside the dogma of ‘the equality of men’, the more must the concept of a normal health, along with a normal diet and the normal course of an illness be abandoned by our physicians. Only then would the time have come to reflect on the health and sicknesses of the soul, and to find the peculiar virtue of each man in the health of his soul: in one person's case this health could, of course, look like the opposite of health in another person.” 14

Normal and normative

Nietzsche claims that we should abandon the concept of a normal health. Let me use that, and his reference to the soul, as a starting point for what I promised to say about science and religion. In this connection, a helpful contrast was drawn by the medical philosopher and historian Georges Canguilhem between two views of what is normal. On the one hand there is the view of disease or malfunction as a deviation from a fixed norm established by medical theory, to which norm medical practice seeks to return the patient. On the other there is the view of the organism as a living being that has no pre-established harmony with its environment. The latter, Canguilhem argues, is the true view of normality. “Being healthy”, he writes:

“means being not only normal in a given situation but also normative in this and other eventual situations. What characterises health is the possibility of transcending the norm, which defines the momentary normal, the possibility of tolerating infractions of the habitual norm and instituting new norms in new situations.” 15

Perhaps a more colloquial way of putting what Canguilhem says here is that health is not a matter of getting back from illness, but getting over and perhaps beyond it. Health, to quote Canguilhem again:

“is a feeling of assurance in life to which no limit is fixed. Valere , from which value derives, means to be in good health in Latin. Health is a way of tackling existence as one feels that one is not only possessor or bearer but also, if necessary, creator of value, establisher of vital norms.” 16

On this view then, to be healthy is not to correspond with some fixed norm, but to make the most of one's life in whatever circumstances one finds oneself, including those which in terms of some fixed norms may seem severely impaired or unhealthy. “To be in good health”, Canguilhem writes, “means being able to fall sick and recover”.

The scientific picture

Canguilhem also, like Leach, comments on the “seduction still exerted on our minds today by the image of the athlete” as the image of health, agreeing on its inappropriateness as an ideal for practically all of the population. Why is this view so seductive? Perhaps because we tend to assume that a modern scientific or “objective” picture of the world, in which we ourselves figure as natural phenomena, is the “true” view of the “real” world. In this scientific picture, it is difficult not to see something like the image of the athlete as the ideal of health—for which all that comes before is a preparation, and all that follows a process of disintegration and decay.

But there is a serious problem about taking this objective scientific picture as the “true” view of the “real” world. The physicist Schrödinger put it as follows. 17 The only way scientists can “master the infinitely intricate problem of nature”, is to simplify it by removing part of the problem from the picture. The part that scientists remove is themselves as conscious knowing subjects. Everything else, including the scientists' own bodies as well as those of other people, remains in the scientific picture, open to scientific investigation. This “objective” picture is then taken for granted as “the ‘real world’ around us”; and because it includes other people who are conscious knowing subjects just as the scientist is, it is difficult for the scientist to resist the conclusion that the “true” picture of the “real world” must be an “objective”picture, which includes the conscious knowing subject as another object. That conclusion, however, fails to fit all the facts. For, as Schrödinger says, this “moderately satisfying [scientific] picture of the world has only been reached at the high price of taking ourselves out of the picture, stepping back into the role of a non-concerned observer”.

The point Schrödinger is making can be difficult to grasp, or at least to hold on to, because the view that an “objective” picture is the “true” picture of the “real world” seems like common sense. It is reflected, for example, in what David Chalmers, in The Conscious Mind, 18 characterises as “Don't-have-a-clue materialism”—the view “held widely, but rarely in print” which says “I don't have a clue about consciousness. It seems utterly mysterious to me. But it must be physical, as materialism must be true”. The problem is that all of us, before we begin to think critically about such questions, have come to experience the world and other people as things “out there”, either inanimate or animate. So is not that, ultimately, the true picture of us also? To deny it feels unreasonable—as unreasonable as it must once have felt to deny that the sun went round the earth. Yet just as science once destroyed that illusion, so too now, science itself is destroying the modern illusion that the “true” picture of the “real world” is an objective one which science, when it has made all its discoveries, will eventually provide.

This message of course has been underlined by modern physics's realisation that, as Schrödinger puts it, “the object is affected by our observation. You cannot obtain any knowledge about an object while leaving it strictly isolated”. Or as Heisenberg observed:

“Science no longer confronts nature as an objective observer, but sees itself as an actor in this interplay between man and nature. The scientific method of analysing, explaining and classifying has become conscious of its limitations, which arise out of the fact that by its intervention science alters and refashions the object of investigation.” 19

“Science no longer confronts nature as an objective observer, but sees itself as an actor in this interplay between man and nature.” The problem about conceiving health in terms of fixed norms such as those of biochemistry, or the ideal of the athlete, is that it assumes that the objective observer's viewpoint is the true one, and discourages those who adopt it from seeing themselves as actors or agents, rather than patients who are acted upon. Daniel Dennett has remarked that “human beings offload as much of their minds as possible into the world”. 20 If we want to gain a more adequate understanding of the meaning of “health”, along the lines Canguilhem suggests, we may have to be prepared to offload rather less, and take responsibility for rather more, of our minds.

That at least seems to be what science itself is now telling us; and in that respect science provides part of the explanation of why definitions of health are, and are likely to remain, elusive. If health is “a way of tackling existence” in which “one is not only possessor or bearer but also, if necessary, creator of value, establisher of vital norms”, then what constitutes health in one person may well, as Nietzsche said, “look like the opposite of health in another person”.

Religious ideas

The final part of the explanation I want to suggest concerns religion. A naïve, albeit widely-held view, is that religious ideas about the world have been disproved by science. What actually happened historically is more complex. Schrödinger again provides a helpful explanation:

“One of the aims, if not perhaps the main task of religious movements has always been to round off the ever unaccomplished understanding of the unsatisfactory and bewildering situation in which man finds himself in the world; to close the disconcerting ‘openness’ of the outlook gained from experience alone, in order to raise his confidence in life and strengthen his natural benevolence and sympathy towards his fellow creatures—innate properties, so I believe, but easily overpowered by personal mishaps and the pangs of misery.” 21

Religion, Schrödinger suggests, has always tried to “round off” or “close the disconcerting ‘openness’” of human experience. In the past, it has done this, often very successfully, in terms of scientific or pre-scientific ideas which at the time seemed plausible to everyone. When these ideas were overtaken by new scientific explanations which seemed to fit the facts better, religion, being more conservative than science, was slow to give them up; and this helped to create the impression among many people that it was only a matter of time before science would explain everything. But this idea of science demonstrating “a self-contained world to which God” (or the religious or transcendent dimension) is “a gratuitous embellishment”, Schrödinger points out, begins to seem unrealistic when we grasp what he is saying about the absence of the conscious knowing subject from the scientific picture of the world. If science were able to exclude the religious or transcendent dimension from reality (rather than just from the scientific picture of reality), it would be at the cost of excluding the first-person human dimension also. But the idea that science can do this, Schrödinger adds, springs not “from people knowing too much—but from people believing that they know a great deal more than they do”.

Insights such as Schrödinger's have not been lost on many more perceptive modern religious thinkers, who see no necessary conflict between religious and scientific ideas. One of the defining attitudes of science, Schrödinger points out, is that in “an honest search for knowledge you quite often have to abide by ignorance for an indefinite period”. 22 But such an acknowledgement of ignorance is also what is required by the Judaeo-Christian rejection of idolatry—superstitious mental pictures or preconceived notions which inhibit open-minded attention to reality in all its variety—and this religious rejection of idolatry, it has often been argued, was what opened the way for modern scientific enquiry. The scientific fides quarens intellectum , moreover, has a strong family resemblance to religious faith as described by two key modern religious thinkers—Kierkegaard, when he remarked that “not only the person who expects absolutely nothing does not have faith, but also the person who expects something particular or who bases his expectancy on something particular” 23 ; and Coleridge, when he wrote that faith “may be defined as fidelity to our own being—so far as such being is not and cannot become an object of the senses; and hence … to being generally, as far as the same is not the object of the senses.” 24

Religious statements of this kind illustrate not only the compatibility of science and religion, but also that the idea of a healthy person as a “creator of value, establisher of vital norms” can be endorsed by religion. Coleridge's famous description of the imagination as “a repetition in the finite mind of the eternal act of creation in the infinite I AM”, 25 for example, implies that religious knowledge of what it calls “God” is analogous not to what is seen by an objective observer, but to what is encountered by Heisenberg's “actor in the interplay”. That this encounter is with reality, is in no way diminished by its taking place through the creative human imagination.

Wholeness, healing and death

For religion, the two remaining words I mentioned at the outset—wholeness and healing—are intimately related. Healing is understood by religion not only as the natural process of tissue regeneration sometimes assisted by medical means, but also as whatever process results in the experience of greater wholeness of the human spirit. Healing in the latter sense need not be religious in form (nature, music or friendship as well as religious rites may be agents of healing), nor accompanied by “cures” or “miracles”. These or other signs of hope, when attested, may be seen as traces of a transcendent or encompassing wholeness, in which human wholeness is grounded. But wholeness is always imperfectly realised in the fragmentariness of human experience; and while for religion the encompassing wholeness is not reducible to a psychological projection, it is discovered most commonly in the mode of expectancy, both in the midst of life and in the face of death.

Religious expectancy

Religious expectancy clearly is not something on which science can have much to say, except perhaps to discourage religion when it too rapidly or rhetorically seeks to close the “disconcerting openness” of experience by interpreting its own experience and expectancy in terms of “something particular”—clinical trials to prove the power of prayer or the validity of near-death experiences, for example. But whether or not religious experience and expectancy represent more than psychological reality, remains part of the disconcerting openness of human experience, which can be closed or rounded off no more conclusively by scientific experiment than by religious dogma. Such questions admit only answers given, not by detached scientific or religious observers, but by or between conscious knowing subjects, the actors in the interplay.

This disconcerting openness perhaps is what, finally, makes the meaning of health, healing and wholeness so elusive. If acknowledging openness means suspending pre-judgment, for example on the realism of expectancy in the face of death, these words may take on counterintuitive meanings:

“A physically dependent patient who has come to terms with his past life and his approaching death, for example, may well feel, and thus (because no one else is better placed to judge) be nearer to ‘wholeness’ than ever before.” 26

Such a person may even, in this perspective, be described as “healthy”.

Whether such counterintuitive meanings are entertained of course, depends on whether the viewpoint of the conscious knowing subject is given at least as much weight as that of the clinical observer. Canguilhem sums up the results of much physiological, pathological and clinical observation as follows.

“Life tries to win against death in all the senses of the verb to win, foremost in the sense of winning in gambling. Life gambles against growing entropy.” 27

But what if entropy grows too great, and life's last throw seems lost? Should the subject in whom life has grown conscious recognise that this time the odds are stacked too heavily against him? Or do all life's attempts to win against death hint to him that a deeper game, with higher stakes, is afoot? Religious arguments underdetermine any conclusive answer to this question. But so too do arguments which reduce first-person experience to third-person psychological, sociological or evolutionary explanations, or reduce the experienced mystery of being a conscious subject to a set of “eventually” solvable scientific problems about the property of consciousness. The disconcerting openness of experience raises a question mark against the conventional assumption that expectancy in the face of death is “no longer available” to critical thought. Might not a more critical stance be to admit ignorance without denying admission to hope? It is difficult to see why that should not remain at least an open question; and as long as it does, the meaning of health, healing and wholeness seems likely to remain elusive.

• ↵ Brown L, ed. The new shorter English dictionary . Oxford: Clarendon Press, 1993.
• ↵ Marinker M. Why make people patients? Journal of Medical Ethics 1975 : I : 81 –4. OpenUrl
• ↵ Showalter E. Hystories . London: Picador, 1997.
• ↵ Micale MS. Strange signs of the times. Times Literary Supplement 1997 May 16 : 6 –7.
• ↵ Unwin C, Blatchley N, Coker W, Ferry S, Hotopf M, Hull L, et al . Health of UK servicemen who served in the Persian Gulf War. Lancet 1999 ; 353 : 169 –78. OpenUrl CrossRef PubMed Web of Science
• ↵ Walton J, Barondess JA, Lock L, eds. The Oxford medical companion . Oxford: Oxford University Press, 1994: 611.
• ↵ Youngson RM. Collins dictionary of medicine . Glasgow: HarperCollins, 1992: 406.
• ↵ See reference 6: 816.
• ↵ Hare RM. Health. Journal of Medical Ethics 1986 ; 12 : 172 –81. OpenUrl
• ↵ Tillich P. The meaning of health . Richmond, California: North Atlantic Books 1981: 43. See also: Kant I. Anthropology from a pragmatic point of view . [Translated by MJ Gregor.] The Hague: Martinus Nijhoff, 1974: 82–83.
• ↵ Downie RS, Fyfe C, Tannahill A. Health promotion: models and values . Oxford: Oxford University Press, 1992.
• ↵ Leach E. Society's expectations of health. Journal of Medical Ethics 1975 ; 1 : 85 –9. OpenUrl FREE Full Text
• ↵ Treves F. The elephant man, and other reminiscences . London: Cassell 1923: 201.
• ↵ Nietzsche F. The gay science . [Translated by W Kaufmann.] New York: Vintage Books, 1974: book III, section 120.
• ↵ Canguilhem G. The normal and the pathological . New York: Zone Books, 1991: 196f.
• ↵ See reference 15: 201.
• ↵ Schrödinger E. What is life ? Cambridge: Cambridge University Press 1967: 118f.
• ↵ Chalmers DJ. The conscious mind . Oxford: Oxford University Press, 1996: 162.
• ↵ Heisenberg W. The physicist's conception of nature . London: Hutchinson, 1958: 29.
• ↵ Dennett DC. Our mind's chief asset. Times Literary Supplement 1997 May 16 : 5 . OpenUrl
• ↵ Schrödinger E. Nature and the Greeks . Cambridge: Cambridge University Press 1996:6.
• ↵ See reference 21: 8.
• ↵ Kierkegaard S. Eighteen upbuilding discourses .[Translated by HV Hong and EH Hong.] Princeton: Princeton University Press 1990: 27.
• ↵ Coleridge ST. Essay on faith. In: Aids to reflection . London: G Bell & Sons, 1913: 341.
• ↵ Coleridge ST. Biographia literaria . London: Bell & Daldy, 1870: 144.
• ↵ Boyd KM. Health care ethics, health and disease. In: Gillon R, ed. Principles of health care ethics. Chichester: John Wiley & Sons 1994: 812.
• ↵ See reference 15: 236.

Kenneth M Boyd is Senior Lecturer in Medical Ethics, Edinburgh University Medical School and Research Director, Institute of Medical Ethics.

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How Concepts of Illness and Health are Culturally Defined

What constitutes illness and health are constructs that vary depending on the cultural context in which they are experienced. By looking at various ethnographic examples from around the world we can show how these concepts are defined differently in various cultures and societies.

Table of Contents

In this essay I will first discuss the definitions of illness and health, after which, using various ethnographic examples, I will illustrate how culture fills in the gaps when it comes to constructing our understanding of what constitutes illness and how this impacts our associated health-seeking behaviours.

In the second part of the essay, I will focus on two ethnographies of women in Haiti and Japan to illustrate the concept of culture-bound syndromes which are in fact a form of indirect and non-confrontational resistance against the pressures and restrictions put on the women by society and the injustices they face at home.

The Definition of Illness

For the scope of this essay, I shall be using the definition of illness as the

“innately human experience of symptoms and suffering. … how the sick person and the members of the family or wider social network perceive, live with, and respond to symptoms and disability” (Kleinman 1988, p. 3)

– as opposed to disease , which is the medicalised interpretation of the signs and symptoms associated with the person’s condition, based on a particular medical taxonomy and leading to an official diagnosis by a practitioner (Kleinman 1988; Singer, Baer 2012; Young 1982).

One could condense the difference between illness and disease by saying that the former is the embodied experience and perception of the condition of the person who is struggling with the illness and the people around them, as opposed to the narrower perspective, stripped of personal and societal illness experience, of the health practitioner to whom they turn for treatment (Kleinman 1988; Singer, Baer 2012; Young 1982).

Thus, a person might get a diagnosis, and it is even possible that they will be prescribed medication to alleviate or cure their symptoms, but this does not necessarily mean that their illness will be resolved, for the illness has associated meanings that cannot be expunged by swallowing a pill or undergoing surgery.

Kleinman (1988, p. 22) describes these societal constructs of illness as an “exoskeleton” that forms around the person, changing the way that society perceives them, and potentially also how they perceive themselves.

To give an example, it is in this manner that a diagnosis of HIV transforms into the stigma of sexual deviancy or promiscuousness (Kleinman 1988).

A person interprets and experiences illness based on the systems of meaning inherent in their culture and formed through their own personal life experiences.

This is how they construct their explanatory model of illness (EM), which incorporates the cause and origin of their illness (aetiology), the pathophysiology (impact on bodily functions), the onset and type of symptoms, how society expects the sick person to behave (the sick role), and the treatment that is necessary to heal.

Thus, the illness experience and the explanatory model constructed for it are unique to each person, impacting their illness behaviours and the approach taken to seek treatment and return to health.

This is why the way we experience illness is culturally defined, as is our health-seeking behaviour (Kleinman 1988; Singer, Baer 2012; Young 1982).

The Definition of Health

Biomedicine defines health as the absence of disease (Singer 2004). This definition, however, does not take into consideration the issue of illness, which as described above encompasses several additional criteria relating to the perceptions and experiences of the person who is ill and the people around them.

The World Health Organisation (WHO) has recognized the reductionist nature of the biomedical definition of health, so it has expanded the definition to include both the absence of disease and the physiological and psychological wellbeing of the individual (Brown, Barrett, Padilla, Finley 2010).

The problem with this definition, of course, is that wellbeing is a very culturally loaded term because it can mean totally different things in different cultures.

A good example that illustrates this issue is the interpretation of a thin body in the US (healthy, attractive) as opposed to Africa (unhealthy, malnourished) (Brown et all 2010; Singer 2004; Singer, Baer 2012).

The abovementioned example leads us to a definition proposed by a branch of Medical Anthropologists focusing on Critical Medical Anthropology , which includes the political and economic circumstances of the individual in question.

For of course, the difference in interpretation of a thin body does not depend solely on culturally defined criteria, but also on the economic reality on the ground.

After all, if people are seriously malnourished or starving there is no way that a thin body can be an indicator of good health (Singer 2004).

Proponents of Critical Medical Anthropology point out that wellbeing depends on a much wider range of criteria than was recognised in the WHO definition, and that true wellbeing cannot be achieved if people are struggling with issues such as social inequality, class, gender, racial and other forms of discrimination , and poverty (Singer 2004).

Thus, they define health as having the resources to live “life at a high level of satisfaction” (Singer, Baer 2012, p. 78).

Explanatory Models and the “Work of Culture”

“The work of culture is the process whereby painful motives and affects such as those occurring in depression are transformed into publicly accepted sets of meanings and symbols.

Thus the constellation of affects that I talked of earlier can, through the work of culture, be transformed in a variety of directions – into Buddhism and into spirit attack and no doubt into other symbolic forms also.” (Obeyesekere 1985, pp. 147 – 148).

Causes of Disease

At the very core of a person’s EM is their belief regarding the cause of their illness. This becomes the foundation on which they construct the interpretation of their symptoms and their health-seeking behaviour.

The Bedouin tribes of the Negev, for example, attribute many types of sickness (such as problems in pregnancy) to the evil eye (known as ‘ ayn’ in Arabic).

In these fellahin societies, the evil eye can emanate either from an envious person ( insija ) or from evil spirits known as jinns ( jinniyah ).

Given these supernatural causes of illness, whenever members of these tribes feel unwell, they use amulets, incantations and spells to disperse the evil forces that are afflicting them (Abu-Rabia 2005).

In India, on the other hand, many illnesses are attributed to pollution – a view that is rooted in culturally defined ways of understanding the body and bodily functions.

A person who touches a menstruating woman, for example, is perceived to be ill, because it is believed that the menstrual blood is transferred from the pores of the woman to the pores of the other person, thus polluting them internally (Shweder as cited Kleinman, 1988 p. 12).

In this case, healing would require a ritual of purification.

Different Interpretations of the Same Symptoms

Furthermore, the very same symptoms that are experienced as an illness in one culture can be interpreted in a totally different manner in another (Kleinman 1988; Obeyesekere 1985).

Obeyesekere illustrates this phenomenon by comparing the different significance given to the constellation of symptoms recognised as “depressive affects” (p. 145) in the West, where they are grouped together and collectively diagnosed as “depression” as per the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, to the totally different way that such symptoms are understood in societies such as the Ashanti or the Yoruba.

In the case of the Ashanti, this “type of a depression seems, in fact, not to be thought of as an illness but accepted as the inevitable lot of most women” (Krause 1968 cited in Obeyesekere 1985, p. 135).

Similarly, for the Yoruba, “while the symptoms were recognized as painful, unpleasant and disabling, they were seen as more or less ‘natural’ results of the vicissitudes of life” (Murphy cited in Obeyesekere 1985, p. 135).

Obeyesekere extends the argument by explaining that the feelings and behaviours which are collectively termed “depression” in the West, manifest as religiosity in Buddhist cultures.

One of the main tenets of Buddhism is the impermanent and illusory nature of man’s existence, and on special holy days devout Buddhists participate in a series of religious activities which include meditation on revulsion,” where the person’s “pain of mind and sorrow” is “articulated in Buddhist terms and expressed in the activity of sil and meditation” (Obeyesekere 1985, p. 143).

The author tells us that in the Sinhalese language, terminology that is related to despair, pain or sorrow is derived from Buddhism and is inextricably linked to religious devotion. Similarly, Sinhalese mythology and morality tales are all linked to the sorrow of existence and the inevitability of death.

These themes are so important in Sinhalese Buddhist culture that those who have not yet suffered such pain are actively encouraged to meditate on sorrow and death “as a step in the larger quest for understanding the world” (Obeyesekere 1985, p. 145).

Thus, the symptoms of what would be called “depression” in the West are conceived in a totally different manner and are not experienced as illness but rather as Buddhist enlightenment.

This aligns with the findings of Kleinman (1998, p. 27), who states that –

“culture fills the space between the immediate embodiment of sickness as physiological process and its mediated (and therefore meaning-laden) experience as human phenomenon.”

As an example, he mentions the rise in chronic pain complaints that are routinely made by North Americans seeking treatment, commenting that in their culture the expectation has now become that life should be totally pain free.

He contrasts this with people in the developing world, who accept the reality

“that pain is an expectable component of living and must be endured in silence” (p. 23).

The author also shares other examples, including menopause, which is framed as an illness in the Western world but is viewed as a natural stage of life in many other cultures (p. 24).

Different Health-Seeking Behaviours

As already mentioned, the health-seeking behaviours of people who are unwell are closely linked to other aspects of their EM, such as their understanding regarding the cause of their illness and their interpretation of their symptoms.

Thus it is, for example, that many people in Iran who are struggling with depression or anxiety, and who attribute their condition to an evil spirit called a bād, seek treatment from a māmā or a bābā, who are Zār practitioners with the required experience to assess whether the Zār healing ritual can help them (Mianji, Semnani 2015).

During the ritual the ill person lies on the floor in the centre of the room, with a cloth placed over his or her head.

To identify exactly which bād they are dealing with, the Zār practitioner begins chanting and altering the music’s rhythm until the patient begins to twitch.

When this happens, the other ritual participants begin to dance in an uncontrolled frenzy, taken over by evil spirits (Mianji, Semnani 2015).

The bād that has possessed the ill person then makes its demands, which are usually something that the afflicted person would not have been able to ask for under “normal” circumstances, but which are acceptable in the liminal stage created by the Zār ritual, when social rules are put on hold (Beeman 2018; Mianji, Semnani 2015; Van Gennep 1960).

The request is then satisfied, and the affliction is alleviated. The person then emerges from the ritual with their needs satisfied, and they reintegrate into society, once more complying with societal expectations and norms.

Illness as Resistance

I will now be looking at illness through the lens of resistance, with a particular focus on how illness manifests in women (both consciously and potentially also subconsciously) as resistance to the domination that they are subjected to in their everyday lives.

I will be referring to ethnographies examining two different culture-bound syndromes: (1) move san in rural Haiti (Farmer 1988); and (2)   futeishūso experienced by Japanese women (Lock 1987).

The main premise of both these ethnographies hinges on the somatization of psychological distress in the form of (apparently unrelated) physical and psychological symptoms, most likely resulting from the fact that these women live in societies where they are under pressure not to confront the source of their distress directly.

In both societies, these women are victims of tactical or organisational power, defined by Eric Wolf (1990) as the typology of power that controls the opportunities and resources available to specific groups, in this case women, in a community.

In both cases, organisational power is being brought to bear upon women both at a societal level and in the micro-relations of everyday life, meaning that they are experiencing multiple levels of domination.

I will also be looking at differences between the two cases, focusing on the fact that while the explanatory models (EMs) used by the women in both societies to describe and justify the illness in question align, there are major differences in the resulting health-seeking behaviours and the EMs of health practitioners they resort to for relief of their symptoms.

Furthermore, I will also show that in some cases, the women’s treatment choices lead to them experiencing a stage of liminality, followed by reintegration into society, in much the same way as the Zār ritual mentioned above.

Ethnography of Haitian Women suffering from Move San in Do Kay

Move san is a condition that mainly afflicts women, particularly when they are in a vulnerable stage of their life, such as when they are pregnant or breastfeeding their children.

The illness is triggered by an event that causes the woman serious emotional distress, such as domestic violence or infidelity on the part of her partner.

The EM of the healer who creates the herbal remedies for this illness is that

“If you are deceived, cheated, cuckolded, ostracized, or frightened, you must beware of move san . It can happen in a short amount of time; within a week you’re very ill” (Farmer 1988, p. 71)

The word move san translates to “bad blood,” which is an accurate description of the way that Haitians conceive this illness.

When a woman experiences a shock or is abused in some manner, her blood becomes infected, infecting all her organs as the blood flows through the body.

The bad blood can lead to a miscarriage in a pregnant woman and the spoiling of breast milk in a nursing mother.

To understand this illness, one must consider the realities faced by the women of Do Kay, who are the victims of multiple levels of organisational power.

A few years before the ethnography was conducted, the village was displaced because a decision was taken at government level to build a dam in the valley.

This involved flooding the village and the entire community lost their homes and land, but were not compensated.

This led to them falling into extreme poverty, and many of the women found themselves needing to work outside the home to make ends meet, making it extremely difficult for them to nurse their babies.

The desperation experienced by the entire community and the sudden shift in gender roles as women left the home to work led to an increase of domestic violence, forming the background to the sudden epidemic of move san (Farmer 1988).

Move san is thus a somatization of the women’s distress, and a form of resistance against the domination that the women are experiencing, both from the State and within their homes.

By announcing that she has move san , a woman is effectively protesting about being mistreated, without engaging in direct confrontation with the parties responsible, which would be frowned upon by society.

She therefore shines a light on the abuse through her illness and creates an obligation on the entire community to protect her from further mistreatment.

Furthermore, she is also creating a pretext for weaning her child early, which had previously been considered mistreatment of the baby, but which is now essential given the fact that the mother needs to go to work (Farmer 1988).

Ethnography of Japanese Women suffering from futeishūso

Japanese culture prioritises societal harmony, predicating that the needs of the individual should be put aside in the interest of the community.

Women are thus under considerable pressure to “dissolve the personal and honor the public (messhi hōkō)” (Harootunian 1974 cited in Lock 1987, p. 118), by never engaging in direct confrontation with others.

They are also socialized to act according to the principles of tatemae (socially acceptable behaviour) and not to indulge their hone (their personal needs and wants) (Lock 1987, p. 122).

Japanese women are subject to various forms of domination.

Society dictates that they should be submissive, and they are judged primarily based on whether they are a “good wife and wise mother” (Lock, p. 128).

They are subject to organisational power (Wolf 1990), since culture dictates that after marriage they should not work outside the home, however educated or skilled they may be.

And finally, they are also expected to be subservient to their husbands, as in the case of college-educated Mrs Morita, whose husband beats her, and yet must make sure that a hot meal is ready as soon as her husband returns from work, which is usually around ten o’clock at night (Lock, p. 134).

Lock tells us that resistance to the homogenizing power experienced by the Japanese comes in two forms – (1) retreatism, which involves separating oneself from society, or (2) ritualism, where the person internalizes their resistance, while acting as though they are totally in harmony with society (Lock 1987, p. 119).

The women’s resistance thus emerges as futeishūso, a constellation of nonspecific symptoms that medical practitioners diagnose as “chronic infectious pelvic disease” (Lock, p. 126), which everyone understands, but never acknowledges publicly, is a euphemism for an illness emerging out of loneliness, boredom and the inability to achieve any form of self-actualisation.

When a woman succumbs to this culture-bound syndrome of symptoms, she receives support from her family and the community, and she is often hospitalized for extended periods of time, in some cases for up to two months.

While they are in hospital, they go through a liminal phase where they can discuss their feelings and life circumstances with their doctor, finally emerging two months later and reintegrating in society after “healing.”

A Comparison of the Two Ethnographies

Similarities.

In both cases the women are the victims of multiple levels of organisational power (Wolf 1990).

The Haitian women lost their homes and became desperately poor through the actions of the State, and in some cases, they are also victims of domestic violence.

The Japanese women, on the other hand, are forced to be submissive and are victimised by society and their husbands.

Both the Haitian and Japanese women have been socialised to avoid direct confrontation, so their illness is a somatization of emotional and psychological distress, publicly declaring their emotional distress in a socially acceptable form.

To heal, the women go through a rite of passage, starting off as ill, then entering a liminal stage where they receive treatment and get lots of attention, after which they emerge and re-integrate within society.

Differences

The circumstances of the women, however, are very different.

In the case of Haiti the women are poor and have to work outside the home, even though this interferes with the way they would like to raise their children.

In the case of Japan, on the other hand, the women are financially stable and, in most cases, do not work outside the home, even should they want to do so

Furthermore, while both the Japanese and the Haitian women acknowledge that the source of their illness is emotional or psychological, their health-seeking behaviour differs.

The Japanese refer to a biomedical doctor and receive treatment for their physical symptoms, while the Haitian women are more likely to initially seek assistance from a local healer, who conducts a ritual to purify their blood.

In conclusion, this essay has shown that the interpretations of illness and health are culturally defined and are incorporated in the EM of the ill person, as well as the EMs of the people they interact with, including the health practitioners they resort to.

These EMs construct their understanding of the causes of their illness, the definition of their symptoms, and very importantly, their health-seeking behaviour.

Thus, we see that a Buddhist in Sri Lanka would view their depressive symptoms as proof of their piety and would not seek any treatment, while a person in the West would view them as symptoms of a disease and would go to the doctor to ask for medication.

We have also seen that illness can be a somatization of emotional and psychological distress, enabling people who are not able to confront the causes of their illness for culturally specific reasons to seek treatment to alleviate their suffering.

In these cases the health-seeking behaviours of the people in question enable them to break free of the restrictive bonds placed on them by their culture to ask for what they want, as happens during the Zār ritual, request support and protection when vulnerable, as done by Haitian women in the guise of move san , or extract themselves for an extended period of time from their loneliness and aimlessness, as done by Japanese women who succumb to futeishūso .

Abu-Rabia, A. (2005) “The Evil Eye and Cultural Beliefs among the Bedouin Tribes of the Negev, Middle East.”  Folklore,  116 (3), pp. 241-254.

Farmer, P. (1988) “Bad Blood, Spoiled Milk: Bodily Fluids as Moral Barometers in Rural Haiti.” American Ethnologist , Vol. 15, No. 1, Medical Anthropology, pp. 62-83.

Beeman, W.O. (2018) “Understanding the Zār: An African-Iranian Healing Dance Ritual.”  Anthropology of the Middle East,  13 (1), pp. 69.

Brown, P., Barrett, R., Padilla, M. and Finley, E. (2010) “Medical Anthropology: An Introduction to the Fields” in P. Brown and R. Barrett (eds.), Understanding and Applying Medical Anthropology . Toronto: McGraw Hill, pp. 3-15.

Gennep, A.V. (1960)  The R ites of P assage.  Phoenix.

Kleinman, A. (1988). The Illness Narratives: Suffering, Healing & the Human Condition. New York: Basic Books, pp.3-30.

Lock, M. (1987) “Protests of a Good Wife and Wise Mother: The Medicalization of Distress in Japan.”  Health, I llness, and M edical C are in Japan: Cultural and S ocial D imensions , pp.130-157.

Mianji, F. and Semnani, Y. (2015) “Zār Spirit Possession in Iran and African Countries: Group Distress, Culture-Bound Syndrome or Cultural Concept of Distress?”  Iranian Journal of Psychiatry , 10 (4), pp. 225-232.

Obeyesekere, G. (1985) “Depression, Buddhism, and the Work of Culture in Sri Lanka.” In Kleinman, A. and Good, B. (eds ). Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder . Berkeley: University of California Press, pp. 134-152.

Singer, M., Baer, H. (2012). Introducing M edical A nthropology: A D iscipline in A ction. AltaMira Press: Lanham.

Singer, M. (2004). “Critical Medical Anthropology.” In: Ember, C.R., Ember, M. (eds) Encyclopedia of Medical Anthropology . Springer: Boston, MA.

Wolf, E.R. (1990) “Facing Power – Old Insights, New Questions.” In Vincent J. (ed.) The Anthropology of Politics . Blackwell Publishers, Oxford, pp. 222 – 233.

Young, A. (1982). “The Anthropologies of Illness and Sickness.” Annual Review of Anthropology , 11, pp. 257-285.

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Essay on Health And Illness

Students are often asked to write an essay on Health And Illness in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Health And Illness

What is health.

Health is about being well and free from sickness. It’s not just about not being sick, but also feeling good in your body and mind. Eating healthy food, getting enough sleep, and exercising regularly can help you stay healthy.

What is Illness?

Illness is when your body is not working as it should. It can be caused by many things, like germs, unhealthy food, or not enough exercise. Illness can make you feel bad and not able to do the things you usually do.

Importance of Health

Being healthy is important because it lets you do the things you love. It also helps you learn better at school. When you’re healthy, you feel good and can enjoy life more.

Preventing Illness

To stay away from illness, you should eat healthy food, exercise, get enough sleep, and wash your hands often. Also, going to the doctor for check-ups can help find any problems early.

Dealing with Illness

If you get sick, it’s important to rest and take care of your body. You might need to take medicine or see a doctor. Remember, it’s okay to ask for help when you’re not feeling well.

250 Words Essay on Health And Illness

Health is when your body and mind are free from sickness or injury. When you are healthy, you feel good and can do all the things you love to do. Eating good food, getting enough sleep, and exercising often are some ways to stay healthy.

Understanding Illness

Illness is when your body or mind is not working properly. It can be a small problem like a cold or a big problem like cancer. Illness can make you feel bad and stop you from doing things you enjoy. Doctors and nurses can help you when you are ill.

The Link Between Health and Illness

Health and illness are two sides of the same coin. When you are healthy, you are not ill. When you are ill, you are not healthy. It’s important to take care of your health to avoid getting ill.

There are many ways to prevent illness. Washing your hands often, eating healthy food, and getting vaccines are some ways to avoid getting sick. It’s also important to get regular check-ups with your doctor.

In conclusion, health and illness are important parts of life. By taking care of your health, you can prevent many illnesses. Remember, it’s always easier to stay healthy than to get better after being sick. So, take care of your health and stay happy!

500 Words Essay on Health And Illness

Understanding health.

Health is a very important part of our life. It is a state where a person is free from sickness. When we are healthy, we can do our daily tasks with ease and happiness. Good health is not just about not being sick. It also means that we are feeling good in our mind and body. We can keep our body healthy by eating good food, doing exercise, and getting enough sleep.

Illness is the opposite of health. It is a state where a person is not feeling well or is suffering from a disease. When we are ill, we cannot do our daily tasks properly. We feel tired and weak. Illness can be caused by many things like germs, not eating proper food, not getting enough sleep, or not doing exercise.

Health and illness are two sides of the same coin. This means that they are closely related. If we do not take care of our health, we can get ill. For example, if we do not eat good food, our body will not get the nutrients it needs to stay healthy. This can make us weak and we can fall ill. Similarly, if we do not get enough sleep, our body cannot rest and recharge. This can also lead to illness.

The best way to prevent illness is to take care of our health. We can do this by eating a balanced diet. This means eating a mix of different types of food like fruits, vegetables, grains, and proteins. We should also do regular exercise. This helps to keep our body strong and fit. We should also make sure to get enough sleep. Sleep is very important because it helps our body to rest and repair itself.

Importance of Regular Check-ups

Another important part of staying healthy is getting regular check-ups. This means going to the doctor even if we are not feeling sick. Regular check-ups can help to find any health problems early. This makes it easier to treat the problem and get better.

In conclusion, health and illness are very important parts of our life. We should always try to stay healthy and avoid illness. This can help us to live a happy and active life. Remember, our health is in our hands. So, let’s take good care of it!

That’s it! I hope the essay helped you.

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The social construction of health and illness

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Senior, M., Viveash, B. (1998). The social construction of health and illness. In: Health and Illness. Skills-based Sociology. Palgrave, London. https://doi.org/10.1007/978-1-349-14087-9_2

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Health-Illness Continuum and Patient Experience Essay

The health-illness continuum belongs to the number of concepts in healthcare that facilitate patient evaluations and allow generalizing on clients’ condition. Proposed more than forty years ago, the idea changed the ways to understand health and reduced unnecessary simplification in that regard. This essay examines the concept in question with reference to patient health and human experience and illustrates its applications to individuals’ health situation.

The continuum explains the meaning of wellbeing and establishes connections between its key components, such as physical, emotional, and mental states. Travis proposed the perspective in the 1970s, stating that it was not beneficial to patient outcomes when healthcare providers regarded health as a dichotomy (Penwell-Waines, Greenawald, & Musick, 2018). The dichotomous approach is limited in its ability to improve people’s health since the ability to eliminate disease and symptoms that reduce patients’ quality of life is seen as the final goal to be reached (Penwell-Waines et al., 2018). Within the framework of the health-illness continuum, the absence of conditions that affect everyday life is perceived as the neutral point between illness and health.

In a good measure, the elimination of disease is the responsibility of healthcare providers whose concerted efforts help patients to reach the mentioned neutral point. After that, the extent to which a person is conscious of his or her health becomes an important variable predicting further progress on the path of reaching high-level wellness (Grénman & Räikkönen, 2015). To pass the point of neutral health that presents false wellness, people are expected to research their personal health risks. Then, moving to high-level health involves engaging in self-study activities to be able to select healthy lifestyle practices that would be beneficial in specific situations (Grénman & Räikkönen, 2015). Therefore, as people move across the illness-wellness continuum, the degree of their responsibility for health outcomes tends to increase.

Summarizing the basic facts about the health-illness continuum, it is possible to say that its relevance to patient health is linked to the prevention of disease recurrence. More specifically, since the continuum goes beyond the dichotomous perspectives of health and illness, it provides new opportunities to implement measures that address health risks in advance (Grénman & Räikkönen, 2015). For instance, when a patient finally achieves the point of neutral health, he or she can be encouraged to move in a forward direction by focusing on self-education and lifestyle improvement. In many cases, this approach can help to reinforce the results of treatment and care provided by specialists.

The concept is relevant to the human experience in healthcare since the use of the health-illness continuum allows encouraging patient participation in the process of wellness improvement. The quality of this experience is predicted by numerous factors, including the ability to reach positive long-term results for patients (Jason, 2017). With that in mind, the continuum is important to consider since it outlines the key steps to be taken after the end of treatment under professional supervision (Grénman & Räikkönen, 2015). To facilitate the achievement of stable and positive health outcomes, it is possible to use the discussed perspective to make patients realize that they can make invaluable contributions to their wellbeing. Therefore, when taken into account, the health continuum can improve the human experience by impacting the lasting results of treatment.

The health-illness continuum is the idea that allows monitoring physical and mental wellness. As for my current state of health, there are no obvious factors and problems that prevent my organ systems from functioning properly. In particular, timely visits to healthcare specialists and attempts to follow medical advice carefully significantly reduced the impact of the health problems that I used to have. Among the behaviors that support my wellbeing today are the readiness to go for regular medical examinations and the constant acquisition of knowledge peculiar to health. More than that, I can call myself a goal-oriented person since I exercise on a regular basis to stay active and full of energy.

To continue, there are specific factors detracting me from achieving high-level wellness. They include, for instance, the presence of unhealthy sleep patterns during the periods of stress. Moreover, being busy with different tasks, I sometimes fail to cook healthy food, which makes my current diet far from perfect and causes the limited consumption of vegetables and fruits. As for wellbeing estimates, on a scale from zero (disease) to ten (optimal wellness), I would give my current condition a rating of seven. In general, my health is good, but there is still room for improvement, and these efforts should be focused on proper nutrition and stress management.

Numerous options and resources can be used to solve the abovementioned issues and approach optimal wellness. To begin with, I can get online and offline nutrition consultations or study the principles of healthy eating using scientific literature (Gesser-Edelsburg & Shalayeva, 2017). Optimal health is impossible without proper nutrition, and this is why the mentioned options are so important (Grénman & Räikkönen, 2015). Such resources will increase my chances to achieve wellness by helping me to understand and address some nutrition mistakes that can give rise to health issues gradually.

To move toward high-level wellness, it is possible to seek the assistance of local mental health professionals or even yoga teachers. I experience stress from time to time, and delving into well-known approaches to stress management can help me to reduce its negative impact on my emotional and physical condition, including occasional sleeping problems. Learning new stress reduction techniques will cause improvements in both physical and mental health, thus giving me more energy to live a wellness lifestyle on a daily basis.

To sum it up, the health-illness continuum is an important perspective that reduces the oversimplification of wellness in healthcare. In nursing practice, this idea should be considered due to its potential effects on long-term treatment outcomes and patients’ awareness of the principles of healthy living. Personally, I am in good health, but my dietary habits and stress coping strategies need to be altered to continue moving toward wellness.

Gesser-Edelsburg, A., & Shalayeva, S. (2017). Internet as a source of long-term and real-time professional, psychological, and nutritional treatment: A qualitative case study among former Israeli Soviet Union immigrants. Journal of Medical Internet Research , 19 (2), e33.

Grénman, M., & Räikkönen, J. (2015). Well-being and wellness tourism – same, but different? Conceptual discussions and empirical evidence. The Finnish Journal of Tourism Research , 11 (1), 7-25.

Jason, A. (2017). The patchwork perspective: A new view for patient experience. Patient Experience Journal , 4 (3), 1-3.

Penwell-Waines, L., Greenawald, M., & Musick, D. (2018). A professional well-being continuum: Broadening the burnout conversation. Southern Medical Journal , 111 (10), 634-635.

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Home — Essay Samples — Nursing & Health — Nursing — Good Health And Wellness

Good Health and Wellness

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Words: 573 |

Published: Mar 13, 2024

Words: 573 | Page: 1 | 3 min read

Table of contents

The importance of good health and wellness, the impact of good health and wellness, achieving and maintaining good health and wellness, the broader implications of good health and wellness.

• In addition to physical health , mental and emotional well-being are equally important. Practices such as mindfulness, meditation, and therapy can help manage stress and improve overall mental health.
• Building a strong support network and nurturing meaningful relationships also contribute to emotional wellness.
• Furthermore, it is essential to prioritize self-care and relaxation. Taking time for oneself, engaging in hobbies, and setting boundaries are crucial for maintaining a balanced and healthy lifestyle.
• Lastly, regular check-ups with healthcare professionals and staying informed about one's health are vital for early detection and prevention of illness.

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The last great stigma

Workers with mental illness experience discrimination that would be unthinkable for other health issues. can this change.

by Pernille Yilmam   + BIO

It is not difficult to find stories about the burdens and barriers faced by employees or job-seekers with mental illness. For example, it was recently reported that Scotland’s police denied a position to a promising trainee because of her use of antidepressants – in keeping with a rule that officers must be without antidepressant treatment for at least two years. In other cases, people have reported being fired from jobs at a university, a nursing home facility, a radio station, and a state agency following requests for medical leave due to postpartum depression, anxiety, depression and bipolar disorder, respectively. A US government commission maintains a select list of resolved lawsuits against companies that involved claims of mistreatment based on a worker’s mental health condition.

Often, the impact of negative attitudes toward mental illness is less overt than in these examples. More than a decade ago, a university professor named Suzanne published a book in which she openly discussed her life with bipolar disorder. The personal details that she revealed in the book, she told me, became a foundation for discriminatory treatment at her workplace. She said she experienced professional isolation in the hallways and meeting rooms: that colleagues stopped inviting her to collaborate with them, that she was shut down in department meetings and cut off from participating in decision-making committees. She attributes these developments to knowledge of her mental illness.

‘I experienced a very noticeable chill, averted eyes, actually being cut off when speaking in meetings,’ Suzanne recalled. ‘Lots of loaded language, of the “Well, SOME people just need to take their meds” variety, in meetings. This was the stage of my professional career where I started calling myself “the crazy lady in the corner”.’ At one point, when she had to take medical leave to address symptoms associated with her condition, a colleague opined that she was ‘lucky’ to have the option.

I n light of such stories, it’s not surprising that concerns about revealing mental health problems at work are commonplace. It’s estimated that 15 per cent of working-age adults have a mental health condition, and in a 2021 survey in the US, three-quarters of workers reported one or more symptoms of mental illness. One study surveying more than 800 people with major depressive disorder worldwide found that between 30 and 45 per cent reported experiencing discrimination in the workplace, with people in high-income countries reporting it at higher rates. A third of US employees polled by the American Psychiatric Association said they were worried about the consequences at work if they sought help for their mental health condition. In England, 61 per cent of survey respondents who were severely affected by mental illness said that ‘the fear of being stigmatised or discriminated against’ stopped them from applying for jobs and promotions. While there are signs that stigma related to mental illness has decreased over time (at least in some countries), stigma and discrimination continue to pose a problem in many workplaces.

Since the 1990s, a number of laws around the world have prohibited discrimination against employees with physical and mental disabilities. Among these are the Americans with Disabilities Act of 1990 in the US, the Disability Discrimination Act 1992 in Australia, and Article 13 of the Amsterdam Treaty of 1997 in the European Union. While these laws have done much to advance protections for people with disabilities, their impact on the treatment of people with mental illness – which constitutes a form of disability for many – has clearly had limits.

Mental illness-related discrimination persists as a multilayered problem characterised by fear, misconceptions and underenforced laws. The encouraging news is that scientists have been developing interventions to help reduce stigma and discrimination related to mental illness – approaches that should receive much more attention if advocates, employers and governments want to make workplaces fairer for all.

Job seekers reluctant to mention a mental illness history were more likely to be employed six months later

Discrimination against people with mental illness is often rooted in preconceived notions about what mental illness is and how it affects someone’s ability to work. These negative misconceptions are forms of mental illness stigma . Research has found that stigma is sometimes expressed by employers and colleagues as an issue of trust: eg, a belief that people with mental illness need more supervision, that they lack initiative, or that they are unable to deal with clients directly. Some might believe that people with mental illness are dangerous, or that they should hold only manual, lower-paying jobs. Research also suggests that many employers and coworkers believe people with mental illness should participate in the workforce, but are reluctant to work with them directly – which has been described as a type of ‘not in my backyard’ phenomenon.

Discriminatory behaviours have been investigated as well. In the US, researchers found that fictitious job applications that mentioned an applicant’s hospitalisation for mental illness led to fewer callbacks than applications noting a hospitalisation for a physical injury. Similar results were observed in Norway. In Germany, scientists found that job seekers who were more reluctant to mention their mental illness history in applications and interviews were more likely to be employed six months later. In addition to the potential impact on hiring, some people with mental illness have told researchers they believe they have been refused a promotion due to their condition.

In one revealing study , Matthew Ridley, an economist at Warwick University in the UK, had pairs of strangers collaborate on a virtual task. Before the task, each participant was shown characteristics of the person they had been matched with, which in some cases included mental illness. Ridley then asked if they wanted to be paired with someone else instead. The participants, he found, tended to be willing to give up some of their anticipated financial compensation to avoid working with a person who had significant depression or anxiety symptoms. When asked why, they indicated that they thought people with a mental illness would be less efficient in completing the task, would require more support, and would be less fun to work with. (For their part, among the participants who revealed to Ridley that they had a mental illness, a majority said they would pay to not have that fact revealed to their partner.)

In the end, participants were paired randomly and, when Ridley analysed the results, he found no differences in task success or enjoyment, regardless of whether someone worked with a person who had a mental illness. The findings capture how negative assumptions can come into play – and prove to be inaccurate – even in the context of a temporary collaboration.

T he perpetuation of mental illness stigma and discrimination comes at a cost not only to the affected individual, but also to companies and societies. The World Health Organization (WHO) estimates that mental illness costs the global economy $1 trillion annually. Among the reasons for these astronomical costs are the higher rates of sick days and unemployment among people with mental illness. The increased absences are partly due to lack of access to treatment; in 2021, it was estimated that only half of all US adults with mental illness had received mental health services in the past year. But a potential aggravating factor is that some employees with mental illness refrain from using their work-associated health insurance for treatment, out of fear that their employer will learn about their condition, resulting in their dismissal, or other forms of discrimination.

The denial of reasonable workplace accommodations could also make a person’s job more difficult and absences more likely. For a person who uses a wheelchair, an accommodation might be a ramp where there are stairs; for a person with a mental health condition, such as an anxiety disorder or ADHD, it could mean having a private office or noise-cancelling headphones to help with concentration problems, or flexibility in one’s work hours in order to attend healthcare appointments or accommodate heightened symptoms. It could also mean requesting leave for a mental health condition – up to 12 weeks in the US, similar to medical leave for physical injuries or for sickness. But some employees might avoid requesting the accommodations they are legally allowed to receive, simply because they suspect that doing so puts their job security and potential for advancement at risk.

The greater amount of absences among people with mental illness can make firings more likely. Losing a job can worsen mental illness, and people often stop applying for new jobs because they anticipate stigma and discrimination.

A list of the top 10 disabilities in US discrimination claims included depression, anxiety disorder and PTSD

Of course, one’s experience of work itself – a major cause of stress for many people – can also contribute to mental illness. One woman I spoke with, whom I’ll call Sara, shared that unsupportive and hostile work environments have made her anxiety even worse than it used to be. She believes that having to take time off work for her mental health led to her sudden termination from her previous job.

Under the Americans with Disabilities Act (ADA), US employers are legally prohibited from discriminating based on physical or mental disabilities at any point during hiring, firing or professional evaluation. The same is true in Australia, based on the Disability Discrimination Act. Other countries have passed antidiscrimination legislation since then too, including South Africa’s Mental Health Care Act 17 of 2002 and India’s Equality Bill, 2019.

Yet, as we’ve seen, decades after the implementation of the ADA, problems remain. Studies continue to document stigma and discrimination against workers with mental illness. In 2020, a list of the top 10 disabilities in US discrimination claims included depression, anxiety disorder and PTSD. In Australia, a commission concluded back in 2004 that the country’s antidiscrimination legislation had been less effective in helping people with mental illness than those with mobility and sensory disabilities. In the EU, where Article 13 of the Amsterdam Treaty created a binding agreement to illegalise discrimination based on disabilities, researchers and clinical professionals were quick to point out its vagueness and lack of defined scope. An EU-funded consensus paper from 2010 documented the continued problem of discrimination against employees and job-seekers with mental illness.

Reports such as these call into question whether even a major law like the ADA can adequately address discrimination related to employee mental illness. And they should prompt us to reconsider how best to combat the problem. One question we can ask is: what might limit the impact of such laws in curbing discrimination against people with mental illness, compared with discrimination against people with physical disabilities? Let’s consider three potential answers.

F irst, discriminatory behaviour is not always obvious, and sometimes it is not even intentional. Compared with an employee who uses a wheelchair, it might be easier to dismiss a socially anxious person’s need to work from home. Compared with someone who is getting treatment for cancer, it might be easier to question whether an employee newly diagnosed with bipolar disorder will ever return as a valuable employee after their medical leave. Compared with a trauma-induced concussion, it might be easier to wonder whether a hypersensitivity to noise, related to PTSD, is really legitimate. Mental illnesses and their effects on people’s daily lives are often less apparent to others than the effects of a physical disability.

Second, laws like the ADA work only if people open up about their disabilities. The physical disability community has in the past decades led a cultural shift from exclusion and shame toward inclusivity and empowerment. People with physical disabilities have community, speak up and exercise their rights. Although there are ongoing efforts by people with mental illness to raise awareness about their experiences, many individuals stay quiet due to shame about their own condition or fear of how others will respond.

Even employers who want to hire people with mental illness can be subject to misguided beliefs

Lastly, the public stigma against mental illness bleeds into what people are expected to be able to handle and achieve. While physical disability is commonly perceived as a challenge with movement, mental illness is perceived as a challenge with thinking. Physical disabilities are seen as being caused by accidents or other unfortunate circumstances, while mental illnesses are often incorrectly seen as a choice or an inherent character flaw. Other misconceptions are that mental illness generally is untreatable or renders people violent or unable to work. An employer might therefore deem a person with mental illness unable to meet their job responsibilities, even when this assumption is unfounded.

Antidiscrimination laws are important, but they do not eliminate the tolls of stigma and capitalism. Employers want to make money, and a mental illness can be seen as a financial liability. Even employers who say they want to hire people with mental illness can be subject to misguided beliefs. And even when companies do grant accommodations, they might be limited. Sara, who in addition to struggling with anxiety has long had difficulty with focusing in distracting environments, was recently diagnosed with ADHD. Together with her psychiatrist, she submitted a request to her large corporate employer to work from home on two weekdays of her choosing, which would enable her to better focus on computer tasks – something that for her is much more difficult in a distracting open-office environment. She told me that it took six months for the accommodation request to be processed; in the end, she was allowed to work from home only on Mondays.

If people can develop the compassion needed to understand why ramps should be installed for use by employees with wheelchairs, there must be a way to heighten compassion for those who would benefit from, for example, a less distracting work environment. But history suggests it won’t be enough to make discriminatory practices illegal. It will require a change in perceptions.

F or many employees or job candidates with a mental illness, the prospect of workplaces free of stigma and discrimination may seem unattainable. ‘I cannot say anything definite that helps [reduce discrimination],’ Suzanne tells me. ‘If you keep your head down and do your job, then good people will eventually accept that this person is still fulfilling their job.’ There are, however, scientifically supported strategies that could be used in efforts to reduce mental illness stigma – and, consequently, discrimination – in workplaces. To the frustration of many anti-stigma advocates, these strategies have not yet been widely implemented.

One basic stigma-reducing strategy is based on social contact. Research suggests that people who have regularly interacted with someone who has personal experience with mental illness (such as a family member, friend or colleague) are often less likely to stigmatise and discriminate, and may be more likely to engage in empathic conversations about mental illness with employees. A law like the ADA should in theory have facilitated more social contact: if it freed more employees to disclose their mental illness and ask for reasonable accommodations, their coworkers would have learned that someone can have a mental illness and still be smart and productive. But, again, many people still do not disclose their mental illness (for fear of discrimination or other reasons), and coworkers cannot learn from what is not disclosed.

Educating HR professionals about mental illness could help reduce discriminatory practices

Another promising method for improving attitudes and behaviour toward employees with mental illness is psychoeducation. Broadly speaking, psychoeducation, also known as mental health education or mental health literacy, is a method of teaching what mental health is, why people might develop mental illnesses, and how these illnesses can be prevented and treated. It can also include the sharing of actionable strategies for coping with symptoms and crises, both acutely and preventatively. Psychoeducation incorporates components of group therapy and cognitive behavioural therapy, and is frequently used by psychiatrists and therapists in clinical settings. It was originally developed to support patients with severe mental illnesses, such as schizophrenia or bipolar disorder, and their families.

Excitingly, psychoeducation can also be used to help change the way workers with mental illness are perceived. While it has been most studied among patient groups as a method to reduce symptom severity and increase healthy coping strategies, it has been employed in professional settings too. For example, a systematic review of studies indicated that psychoeducational training for managers can improve their ‘knowledge, attitudes and self-reported behaviour in supporting employees experiencing mental health problems’. One study reported that managers who received psychoeducational training felt more confident in talking with employees about mental illness and were more likely to reach out to an employee who had an extended absence due to mental illness or stress. Researchers have also suggested that educating human-resources professionals about mental illness could help reduce discriminatory practices. Recently, the implementation of psychoeducational programmes in six companies within high-stress industries (such as hospitality) was found to reduce ratings of stress among workers and mental illness stigmatisation among workers.

The results from these studies are encouraging. Because psychoeducation can be delivered virtually in group settings and can be led by non-experts who’ve received appropriate training, it is also a cost-effective, scalable method. (Full disclosure: last year, I founded a nonprofit that has started to offer psychoeducational services in schools and other organisations.) But, for now, this approach appears to be rarely deployed in workplaces outside of research studies.

T he psychoeducation programmes in these studies typically take place in weekly, one- to two-hour sessions, lasting from a few weeks to months, and they are most often led by mental health professionals. They tend to focus on teaching people about and facilitating conversations on the causes, types, presentation and treatments of mental illness. The programmes often spend a considerable amount of time debunking common myths about mental health, and provide exercises to enable participants to help themselves or others with a mental illness. These exercises might include cognitive-behavioural tools for ‘fact-checking’ thought patterns, problem-solving skills, daily mood journals, and breathing exercises. A major goal is to challenge ideas about mental illness that underlie stigma and discrimination.

In a 2022 policy brief on mental health at work, the WHO argued for greater efforts to improve mental health literacy and support employees with mental illness. Psychoeducational programmes could be a prime tool for pursuing these goals, a staple for companies that aim to comply with antidiscrimination law and improve employee wellbeing. If psychoeducation helps key stakeholders, such as employers and human-resources professionals, to treat employees and job candidates with greater understanding, that might also lead to fewer sick days, enhanced productivity and more employment among people with mental illness. Perhaps work itself will become a less prominent driver of stress.

Some companies currently provide offerings such as unlimited vacation days, meditation apps or yoga sessions as a way to show support for employees’ wellbeing. But these sorts of benefits likely do little to address stigma or discrimination in workplaces. Moreover, implicit in this strategy is the idea that mental illness is a problem that can and should be addressed by individual employees, without putting broader workplace conventions and beliefs into question.

‘In contrast to my mental illness, my concussion was immediately accommodated’

While a severe version of a state such as psychosis or mania can be devastating for the person experiencing it, most people who have a mental health condition are not dealing with crises from day to day. Yes, someone with mental illness might be more easily distracted, more sensitive to noise or less social, but that doesn’t mean that their symptoms will inevitably hamper their job performance. What does hamper performance is when companies neglect to provide reasonable accommodations, even when studies suggest that the benefits associated with providing such accommodations outweigh the costs.

Wouldn’t most companies be inclined to provide structural and logistical support for an employee who suddenly became paraplegic, or who suffered another disabling physical ailment? One former tech industry employee told me that she saw a marked difference in how her leave-taking was received depending on whether it was mental health-related or not. ‘A while after returning from my mental health leave,’ she says, ‘I got a concussion for which I needed partial leave. The symptoms I had were so similar to my PTSD but, in contrast to my mental illness, my concussion was immediately accommodated with a 90-day medical leave and temporary part-time work schedule without any stigma.’ Sara, too, noticed a stark difference when she needed medical leave and other task-related accommodations to recover from shoulder surgery, as opposed to accommodations related to her mental health.

The evidence of ongoing and unnecessary burdens on workers with mental illness calls for honest consideration of what previous antidiscrimination measures have and have not achieved. Employers and governments have yet to fulfil the promise of landmark antidiscrimination laws for the many millions of people who go to work with mental health conditions. Fortunately, there is hope that evidence-backed approaches such as psychoeducational programmes could – if more widely embraced – provide an effective tool for making workplaces fairer and more supportive.

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When Prison and Mental Illness Amount to a Death Sentence

The downward spiral of one inmate, Markus Johnson, shows the larger failures of the nation’s prisons to care for the mentally ill.

Supported by

By Glenn Thrush

Photographs by Carlos Javier Ortiz

Glenn Thrush spent more than a year reporting this article, interviewing close to 50 people and reviewing court-obtained body-camera footage and more than 1,500 pages of documents.

• Published May 5, 2024 Updated May 7, 2024

Markus Johnson slumped naked against the wall of his cell, skin flecked with pepper spray, his face a mask of puzzlement, exhaustion and resignation. Four men in black tactical gear pinned him, his face to the concrete, to cuff his hands behind his back.

He did not resist. He couldn’t. He was so gravely dehydrated he would be dead by their next shift change.

Listen to this article with reporter commentary

“I didn’t do anything,” Mr. Johnson moaned as they pressed a shield between his shoulders.

It was 1:19 p.m. on Sept. 6, 2019, in the Danville Correctional Center, a medium-security prison a few hours south of Chicago. Mr. Johnson, 21 and serving a short sentence for gun possession, was in the throes of a mental collapse that had gone largely untreated, but hardly unwatched.

He had entered in good health, with hopes of using the time to gain work skills. But for the previous three weeks, Mr. Johnson, who suffered from bipolar disorder and schizophrenia, had refused to eat or take his medication. Most dangerous of all, he had stealthily stopped drinking water, hastening the physical collapse that often accompanies full-scale mental crises.

Mr. Johnson’s horrific downward spiral, which has not been previously reported, represents the larger failures of the nation’s prisons to care for the mentally ill. Many seriously ill people receive no treatment . For those who do, the outcome is often determined by the vigilance and commitment of individual supervisors and frontline staff, which vary greatly from system to system, prison to prison, and even shift to shift.

The country’s jails and prisons have become its largest provider of inpatient mental health treatment, with 10 times as many seriously mentally ill people now held behind bars as in hospitals. Estimating the population of incarcerated people with major psychological problems is difficult, but the number is likely 200,000 to 300,000, experts say.

Many of these institutions remain ill-equipped to handle such a task, and the burden often falls on prison staff and health care personnel who struggle with the dual roles of jailer and caregiver in a high-stress, dangerous, often dehumanizing environment.

In 2021, Joshua McLemore , a 29-year-old with schizophrenia held for weeks in an isolation cell in Jackson County, Ind., died of organ failure resulting from a “refusal to eat or drink,” according to an autopsy. In April, New York City agreed to pay $28 million to settle a lawsuit filed by the family of Nicholas Feliciano, a young man with a history of mental illness who suffered severe brain damage after attempting to hang himself on Rikers Island — as correctional officers stood by.

Mr. Johnson’s mother has filed a wrongful-death suit against the state and Wexford Health Sources, a for-profit health care contractor in Illinois prisons. The New York Times reviewed more than 1,500 pages of reports, along with depositions taken from those involved. Together, they reveal a cascade of missteps, missed opportunities, potential breaches of protocol and, at times, lapses in common sense.

Prison officials and Wexford staff took few steps to intervene even after it became clear that Mr. Johnson, who had been hospitalized repeatedly for similar episodes and recovered, had refused to take medication. Most notably, they did not transfer him to a state prison facility that provides more intensive mental health treatment than is available at regular prisons, records show.

The quality of medical care was also questionable, said Mr. Johnson’s lawyers, Sarah Grady and Howard Kaplan, a married legal team in Chicago. Mr. Johnson lost 50 to 60 pounds during three weeks in solitary confinement, but officials did not initiate interventions like intravenous feedings or transfer him to a non-prison hospital.

And they did not take the most basic step — dialing 911 — until it was too late.

There have been many attempts to improve the quality of mental health treatment in jails and prisons by putting care on par with punishment — including a major effort in Chicago . But improvements have proved difficult to enact and harder to sustain, hampered by funding and staffing shortages.

Lawyers representing the state corrections department, Wexford and staff members who worked at Danville declined to comment on Mr. Johnson’s death, citing the unresolved litigation. In their interviews with state police investigators, and in depositions, employees defended their professionalism and adherence to procedure, while citing problems with high staff turnover, difficult work conditions, limited resources and shortcomings of co-workers.

But some expressed a sense of resignation about the fate of Mr. Johnson and others like him.

Prisoners have “much better chances in a hospital, but that’s not their situation,” said a senior member of Wexford’s health care team in a deposition.

“I didn’t put them in prison,” he added. “They are in there for a reason.”

Markus Mison Johnson was born on March 1, 1998, to a mother who believed she was not capable of caring for him.

Days after his birth, he was taken in by Lisa Barker Johnson, a foster mother in her 30s who lived in Zion, Ill., a working-class city halfway between Chicago and Milwaukee. Markus eventually became one of four children she adopted from different families.

The Johnson house is a lively split level, with nieces, nephews, grandchildren and neighbors’ children, family keepsakes, video screens and juice boxes. Ms. Johnson sits at its center on a kitchen chair, chin resting on her hand as children wander over to share their thoughts, or to tug on her T-shirt to ask her to be their bathroom buddy.

From the start, her bond with Markus was particularly powerful, in part because the two looked so much alike, with distinctive dimpled smiles. Many neighbors assumed he was her biological son. The middle name she chose for him was intended to convey that message.

“Mison is short for ‘my son,’” she said standing over his modest footstone grave last summer.

He was happy at home. School was different. His grades were good, but he was intensely shy and was diagnosed with attention deficit hyperactivity disorder in elementary school.

That was around the time the bullying began. His sisters were fierce defenders, but they could only do so much. He did the best he could, developing a quick, taunting tongue.

These experiences filled him with a powerful yearning to fit in.

It was not to be.

When he was around 15, he called 911 in a panic, telling the dispatcher he saw two men standing near the small park next to his house threatening to abduct children playing there. The officers who responded found nothing out of the ordinary, and rang the Johnsons’ doorbell.

He later told his mother he had heard a voice telling him to “protect the kids.”

He was hospitalized for the first time at 16, and given medications that stabilized him for stretches of time. But the crises would strike every six months or so, often triggered by his decision to stop taking his medication.

His family became adept at reading signs he was “getting sick.” He would put on his tan Timberlands and a heavy winter coat, no matter the season, and perch on the edge of his bed as if bracing for battle. Sometimes, he would cook his own food, paranoid that someone might poison him.

He graduated six months early, on the dean’s list, but was rudderless, and hanging out with younger boys, often paying their way.

His mother pointed out the perils of buying friendship.

“I don’t care,” he said. “At least I’ll be popular for a minute.”

Zion’s inviting green grid of Bible-named streets belies the reality that it is a rough, unforgiving place to grow up. Family members say Markus wanted desperately to prove he was tough, and emulated his younger, reckless group of friends.

Like many of them, he obtained a pistol. He used it to hold up a convenience store clerk for $425 in January 2017, according to police records. He cut a plea deal for two years of probation, and never explained to his family what had made him do it.

But he kept getting into violent confrontations. In late July 2018, he was arrested in a neighbor’s garage with a handgun he later admitted was his. He was still on probation for the robbery, and his public defender negotiated a plea deal that would send him to state prison until January 2020.

An inpatient mental health system

Around 40 percent of the about 1.8 million people in local, state and federal jails and prison suffer from at least one mental illness, and many of these people have concurrent issues with substance abuse, according to recent Justice Department estimates.

Psychological problems, often exacerbated by drug use, often lead to significant medical problems resulting from a lack of hygiene or access to good health care.

“When you suffer depression in the outside world, it’s hard to concentrate, you have reduced energy, your sleep is disrupted, you have a very gloomy outlook, so you stop taking care of yourself,” said Robert L. Trestman , a Virginia Tech medical school professor who has worked on state prison mental health reforms.

The paradox is that prison is often the only place where sick people have access to even minimal care.

But the harsh work environment, remote location of many prisons, and low pay have led to severe shortages of corrections staff and the unwillingness of doctors, nurses and counselors to work with the incarcerated mentally ill.

In the early 2000s, prisoners’ rights lawyers filed a class-action lawsuit against Illinois claiming “deliberate indifference” to the plight of about 5,000 mentally ill prisoners locked in segregated units and denied treatment and medication.

In 2014, the parties reached a settlement that included minimum staffing mandates, revamped screening protocols, restrictions on the use of solitary confinement and the allocation of about $100 million to double capacity in the system’s specialized mental health units.

Yet within six months of the deal, Pablo Stewart, an independent monitor chosen to oversee its enforcement, declared the system to be in a state of emergency.

Over the years, some significant improvements have been made. But Dr. Stewart’s final report , drafted in 2022, gave the system failing marks for its medication and staffing policies and reliance on solitary confinement “crisis watch” cells.

Ms. Grady, one of Mr. Johnson’s lawyers, cited an additional problem: a lack of coordination between corrections staff and Wexford’s professionals, beyond dutifully filling out dozens of mandated status reports.

“Markus Johnson was basically documented to death,” she said.

‘I’m just trying to keep my head up’

Mr. Johnson was not exactly looking forward to prison. But he saw it as an opportunity to learn a trade so he could start a family when he got out.

On Dec. 18, 2018, he arrived at a processing center in Joliet, where he sat for an intake interview. He was coherent and cooperative, well-groomed and maintained eye contact. He was taking his medication, not suicidal and had a hearty appetite. He was listed as 5 feet 6 inches tall and 256 pounds.

Mr. Johnson described his mood as “go with the flow.”

A few days later, after arriving in Danville, he offered a less settled assessment during a telehealth visit with a Wexford psychiatrist, Dr. Nitin Thapar. Mr. Johnson admitted to being plagued by feelings of worthlessness, hopelessness and “constant uncontrollable worrying” that affected his sleep.

He told Dr. Thapar he had heard voices in the past — but not now — telling him he was a failure, and warning that people were out to get him.

At the time he was incarcerated, the basic options for mentally ill people in Illinois prisons included placement in the general population or transfer to a special residential treatment program at the Dixon Correctional Center, west of Chicago. Mr. Johnson seemed out of immediate danger, so he was assigned to a standard two-man cell in the prison’s general population, with regular mental health counseling and medication.

Things started off well enough. “I’m just trying to keep my head up,” he wrote to his mother. “Every day I learn to be stronger & stronger.”

But his daily phone calls back home hinted at friction with other inmates. And there was not much for him to do after being turned down for a janitorial training program.

Then, in the spring of 2019, his grandmother died, sending him into a deep hole.

Dr. Thapar prescribed a new drug used to treat major depressive disorders. Its most common side effect is weight gain. Mr. Johnson stopped taking it.

On July 4, he told Dr. Thapar matter-of-factly during a telehealth check-in that he was no longer taking any of his medications. “I’ve been feeling normal, I guess,” he said. “I feel like I don’t need the medication anymore.”

Dr. Thapar said he thought that was a mistake, but accepted the decision and removed Mr. Johnson from his regular mental health caseload — instructing him to “reach out” if he needed help, records show.

The pace of calls back home slackened. Mr. Johnson spent more time in bed, and became more surly. At a group-therapy session, he sat stone silent, after showing up late.

By early August, he was telling guards he had stopped eating.

At some point, no one knows when, he had intermittently stopped drinking fluids.

‘I’m having a breakdown’

Then came the crash.

On Aug. 12, Mr. Johnson got into a fight with his older cellmate.

He was taken to a one-man disciplinary cell. A few hours later, Wexford’s on-site mental health counselor, Melanie Easton, was shocked by his disoriented condition. Mr. Johnson stared blankly, then burst into tears when asked if he had “suffered a loss in the previous six months.”

He was so unresponsive to her questions she could not finish the evaluation.

Ms. Easton ordered that he be moved to a 9-foot by 8-foot crisis cell — solitary confinement with enhanced monitoring. At this moment, a supervisor could have ticked the box for “residential treatment” on a form to transfer him to Dixon. That did not happen, according to records and depositions.

Around this time, he asked to be placed back on his medication but nothing seems to have come of it, records show.

By mid-August, he said he was visualizing “people that were not there,” according to case notes. At first, he was acting more aggressively, once flicking water at a guard through a hole in his cell door. But his energy ebbed, and he gradually migrated downward — from standing to bunk to floor.

“I’m having a breakdown,” he confided to a Wexford employee.

At the time, inmates in Illinois were required to declare an official hunger strike before prison officials would initiate protocols, including blood testing or forced feedings. But when a guard asked Mr. Johnson why he would not eat, he said he was “fasting,” as opposed to starving himself, and no action seems to have been taken.

‘Tell me this is OK!’

Lt. Matthew Morrison, one of the few people at Danville to take a personal interest in Mr. Johnson, reported seeing a white rind around his mouth in early September. He told other staff members the cell gave off “a death smell,” according to a deposition.

On Sept. 5, they moved Mr. Johnson to one of six cells adjacent to the prison’s small, bare-bones infirmary. Prison officials finally placed him on the official hunger strike protocol without his consent.

Mr. Morrison, in his deposition, said he was troubled by the inaction of the Wexford staff, and the lack of urgency exhibited by the medical director, Dr. Justin Young.

On Sept. 5, Mr. Morrison approached Dr. Young to express his concerns, and the doctor agreed to order blood and urine tests. But Dr. Young lived in Chicago, and was on site at the prison about four times a week, according to Mr. Kaplan. Friday, Sept. 6, 2019, was not one of those days.

Mr. Morrison arrived at work that morning, expecting to find Mr. Johnson’s testing underway. A Wexford nurse told him Dr. Young believed the tests could wait.

Mr. Morrison, stunned, asked her to call Dr. Young.

“He’s good till Monday,” Dr. Young responded, according to Mr. Morrison.

“Come on, come on, look at this guy! You tell me this is OK!” the officer responded.

Eventually, Justin Duprey, a licensed nurse practitioner and the most senior Wexford employee on duty that day, authorized the test himself.

Mr. Morrison, thinking he had averted a disaster, entered the cell and implored Mr. Johnson into taking the tests. He refused.

So prison officials obtained approval to remove him forcibly from his cell.

‘Oh, my God’

What happened next is documented in video taken from cameras held by officers on the extraction team and obtained by The Times through a court order.

Mr. Johnson is scarcely recognizable as the neatly groomed 21-year-old captured in a cellphone picture a few months earlier. His skin is ashen, eyes fixed on the middle distance. He might be 40. Or 60.

At first, he places his hands forward through the hole in his cell door to be cuffed. This is against procedure, the officers shout. His hands must be in back.

He will not, or cannot, comply. He wanders to the rear of his cell and falls hard. Two blasts of pepper spray barely elicit a reaction. The leader of the tactical team later said he found it unusual and unnerving.

The next video is in the medical unit. A shield is pressed to his chest. He is in agony, begging for them to stop, as two nurses attempt to insert a catheter.

Then they move him, half-conscious and limp, onto a wheelchair for the blood draw.

For the next 20 minutes, the Wexford nurse performing the procedure, Angelica Wachtor, jabs hands and arms to find a vessel that will hold shape. She winces with each puncture, tries to comfort him, and grows increasingly rattled.

“Oh, my God,” she mutters, and asks why help is not on the way.

She did not request assistance or discuss calling 911, records indicate.

“Can you please stop — it’s burning real bad,” Mr. Johnson said.

Soon after, a member of the tactical team reminds Ms. Wachtor to take Mr. Johnson’s vitals before taking him back to his cell. She would later tell Dr. Young she had been unable to able to obtain his blood pressure.

“You good?” one of the team members asks as they are preparing to leave.

“Yeah, I’ll have to be,” she replies in the recording.

Officers lifted him back onto his bunk, leaving him unconscious and naked except for a covering draped over his groin. His expressionless face is visible through the window on the cell door as it closes.

‘Cardiac arrest.’

Mr. Duprey, the nurse practitioner, had been sitting inside his office after corrections staff ordered him to shelter for his own protection, he said. When he emerged, he found Ms. Wachtor sobbing, and after a delay, he was let into the cell. Finding no pulse, Mr. Duprey asked a prison employee to call 911 so Mr. Johnson could be taken to a local emergency room.

The Wexford staff initiated CPR. It did not work.

At 3:38 p.m., the paramedics declared Markus Mison Johnson dead.

Afterward, a senior official at Danville called the Johnson family to say he had died of “cardiac arrest.”

Lisa Johnson pressed for more information, but none was initially forthcoming. She would soon receive a box hastily crammed with his possessions: uneaten snacks, notebooks, an inspirational memoir by a man who had served 20 years at Leavenworth.

Later, Shiping Bao, the coroner who examined his body, determined Mr. Johnson had died of severe dehydration. He told the state police it “was one of the driest bodies he had ever seen.”

For a long time, Ms. Johnson blamed herself. She says that her biggest mistake was assuming that the state, with all its resources, would provide a level of care comparable to what she had been able to provide her son.

She had stopped accepting foster care children while she was raising Markus and his siblings. But as the months dragged on, she decided her once-boisterous house had become oppressively still, and let local agencies know she was available again.

“It is good to have children around,” she said. “It was too quiet around here.”

Read by Glenn Thrush

Audio produced by Jack D’Isidoro .

Glenn Thrush covers the Department of Justice. He joined The Times in 2017 after working for Politico, Newsday, Bloomberg News, The New York Daily News, The Birmingham Post-Herald and City Limits. More about Glenn Thrush

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