Meet Betty, a typical aging American. At 82, she spends almost as much time with her doctors as she does with her grandchildren. She has to. She takes seven prescription medications to treat her high blood pressure, high cholesterol, diabetes, and arthritis. Ten years ago, she was treated for breast cancer.

Is Betty healthy? According to her, “Absolutely!” She enjoys her spacious apartment, two cats, close friends, and 50-gallon fish tank.

But according to the World Health Organization, Betty is mistaken. The WHO defines health as a state of “complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The Centers for Disease Control and Prevention, along with a range of WHO partners, endorses this definition.

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Being healthy, in their view, excludes having any disease.

Once upon a time, this definition made sense. Today, managing disease, not solely its absence, is a means to a healthy life, especially for older adults. Rather than pursuing the “absence” of disease, we need a more inclusive definition of health — one that works for more people — rather than categorically excluding an entire segment of the life course. A definition of health needs to work for a nation. And most nations in both the developed and developing world are aging.

Seventy years ago, the WHO definition of health was a powerful clarion call to international action. Global life expectancy then was approximately 48 for men and 53 for women. Polio and diphtheria were rampant. Reducing infant and childhood mortality — key drivers of these low life expectancies — was health policy priority number one.

Today, polio and diphtheria, along with measles, tuberculosis and pertussis, are largely preventable and treatable. Chronic diseases, like those Betty is living with, have also been transformed since the 1950s. Heart disease, cancer, and stroke were the top three causes of death for Americans at mid-century, and they remain so today. But their definition, diagnosis, and management are now distinctly different.

President Franklin Delano Roosevelt, for example, had blood pressure readings recorded at 230/140 mm Hg in the year he died, 1945. His blood pressure was so high he suffered from headaches, swelling, and eventually died from a hemorrhagic stroke. Today, guidelines encourage physicians and their patients to begin treatment when blood pressure edges above 130/80 mm Hg, which is considered to be stage 1 hypertension. There are typically no symptoms associated with this stage.

Cancer is also now detected at ever-earlier stages (Betty’s was detected by a mammogram), and the continuous development of therapies, as well as lifelong screening and management, has radically altered survival with cancer. The beside practice of medicine with its focus on the patient’s history of illness and the relief of suffering has given way to a desktop practice dedicated to running the numbers, calculating risks, and relieving anxieties.

A definition of “complete” health as the absence of disease leaves little space for people with chronic diseases and for managing them in new ways. Together, the increasing numbers of Americans over age 65 (currently 51 million) and even over age 85 (currently 6.5 million), with more than 617 million over age 65 worldwide, along with transformations in disease definitions and treatment, amplify the dissonance between the experience of living long and the definition of health.

Having disease and feeling healthy are no longer mutually exclusive, especially for older adults. Managing multiple diseases is the norm for older Americans — approximately two-thirds of adults over age 65 and more than three-quarters over age 85 are managing two or more diseases, while many report being in good or very good health. High blood pressure, diabetes, high cholesterol, arthritis, kidney disease, thyroid conditions, and osteoporosis are among the most common chronic conditions, but with regular access to continuous medical care, these and many more can be managed well, sometimes even without symptoms.

Managing multiple diseases, maximizing function, optimizing medication regimens, prioritizing different health risks and outcomes, and preparing for end-of-life considerations are some of the areas that deserve to be included in basic definitions of health. As we write in the August issue of the American Journal of Public Health, we believe that a definition of health should include adapting to evolving health needs over the life course and optimally managing disease as a means to physical, mental, and social well-being.

There are times when the absence of disease is a perfect goal — vaccination in older adults remains important, for example, and being free of influenza should be a public health goal for old and young alike. But we also need to incorporate early and excellent management of disease as part of health, with objectives for prioritizing risks and benefits according to an individual’s evolving needs, priorities, and health profile over the life course.

This expansion of health to include aspects of disease management is not an excuse for a failing health care system — one that accepts the presence of disease without seeking to minimize and manage it, or one that fails to address suffering through evidence-based practices. The elderly face particular vulnerabilities, including neglect, abuse, poverty, stigma, and marginalization. These experiences deserve special consideration in both health and human rights frameworks. Betty, however, has easy access to care, transportation, a stable income, and a network of friends and family watching over her.

Developing a definition of health that works for everyone — or, perhaps, that works for more people across different segments of the life course — will allow older adults the chance to be healthy. We should revise our definitions of health to account for the need for early and excellent disease management. Managing disease, and not solely its absence, is a means to a healthy life.

Cara Kiernan Fallon, Ph.D., is a postdoctoral fellow in the Department of Medical Ethics and Health Policy at the University of Pennsylvania. Jason Karlawish, M.D., is a professor of medicine, medical ethics and health policy, and neurology at the University of Pennsylvania and co-director of the Penn Memory Center.

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  • … “[Not]Having “education” and feeling “educated” are no longer mutually exclusive”… Let’s change the definition of formal degrees too. Let’s expand educational degrees to include “aspects” of educational degrees. So my MA, is now a Ph.D, when you combine my experiences and studies. This works better for me and my family because it opens up the job market to me, and will provide me and my family with a better quality of life, and because I feel like my academic and life experience qualifies me for it, so be it. I too deserve not to be discriminated against. Let’s call my life + academic accomplishments a PhD! What’s truth anyway… when the alternative profits P$arma? Far out stuff! Let’s include this type of propaganda up there in bills with fascist vaccine mandates. Vaccine injury can now be written off as “normal” and “healthy.” You were paralyzed/got encephalitis/have seizures/developed food allergies/asthma…? You’re HEALTHY!!! Brave New World!

  • So, we should change the definition of health, to a definition that “works for more people” so that people with multiple diseases get to refer to themselves as “healthy”? So this is like, for individual bragging rights? To boost self esteem in people with diseases? So that people with diseases dont feel “left out from the crowd ” of actual, disease free, HEALTHY people?

    I think my real question is, what is your end game here? There is clearly some sort of underlying motive hidden between these words, to make living with diseases seem “normal” and okay, and to make it seem as though an actual “healthy” (disease free) person is so rare nowadays that we all might as well just take that pill, eat McDonalds everyday, and settle for the fact that the doctor’s word is The Last Word and there is absolutely never a reason why we shouldnt trust what doctors, or the CDC, or the FDA says.

    • I 100% agree with Andrew. This whole article is troubling and frankly, absurd. Rather than trying to help people live healthier lives by doing things that are absolutely proven to be good for them (ie preventative of disease) – oh I don’t know, say eating healthy organic and natural whole (unprocessed) foods, drinking unadulterated (ie non fluoridated) water, exercising regularly and vigorously, meditating and partaking in other activities that relax the mind and body, sleeping more, caring more and being more empathetic, laughing heartily and often, spending more time with friends and family building strong relationships and support networks, reading, thinking independently and questioning every Tom, dick and Harry with a PhD that tries to encourage you not to think too much or too hard (of course, they can do that for you, dummy :), this article suggests we should just change the definition of what is healthy. Yeah! That will really help people actually be healthier and have fewer diseases…..of course, the logic is obvious. We’ll just cook the books and push more drugs on sicker people, but they will feel better about themselves, because we have now redefined them as healthy! Thank you researchers for a job well done, say all the big pharma companies……

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