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.
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.