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.

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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.

  • Was this really written by a PhD? You expect us to believe that HEALTH is NOT the absence of disease or chronic illness? Is this satire? Are people dumb enough to buy this?

    • I agree Allison. Do they think we are stupid? Health is lack of dis-ease. Eating the fuel god created for his perfect engine. Being on any prescription drug IS NOT HEALTHY!

  • True health NEVER is a question of enough vaccines, enough medications and… enough doctors and hospitals!

  • So you’re advocating for participation trophies so people won’t feel bad for being unhealthy?

  • I do not agree that we should redefine health. It took 10 years for doctors to diagnose my medical condition because I was repeatedly told that my symptoms were normal. They were not normal and my medical condition was not diagnosed until it was extremely severe. Redefining healthy as what is abnormal will only make the situation worse. Medical Doctors need to have a better understanding of what is healthy so they can diagnose disease in a very early stage. I have multiple medical conditions that adversely impact my health. I am NOT healthy! If my medical conditions are well-managed, I am able to have a good quality of life. When doctors ignore me when I tell them I am suffering from symptoms of disease, my quality of life is very poor. Redefining health as people with multiple diseases will only cause more doctors to ignore what their patients tell them and worsen the quality of life for countless people. Healthy and normal is living a life without the presence of disease and without dependence on medication. It is not normal or healthy to have multiple diseases or be dependent on multiple medications. However, medical conditions and diseases should be diagnosed at an earlier stage so that they can be managed and people can have a good quality of life.

  • Health and heal come from the same root word as whole, holy.
    If we see health as wholeness, as connection to ourselves, our families, our gifts, our pasts and futures, then we acknowledge the things that we all value. And we create room for health even in the midst of dis=ease.

  • This is an interesting point of view. The first thing that comes to mind is that the WHO has already suggested the notion of Healthy Ageing “as the process of developing and maintaining the functional ability that enables wellbeing in older age”, where functional ability consists of intrinsic capacity (=current level of health) + supportive and age-friendly environment. In this regard, modification of the definition of health seems not needed.

    Furthermore, lowering the standard of health (which, in my view, this suggestion is aimed at) would make sense if curing chronic diseases was not possible in principle. However, geroscience is increasingly progressing in bringing age-related diseases under medical control by a wide range of interventions, from gene therapies that are aimed at removing genetic vulnerability to these diseases to senolytics (drugs that selectively target senescent cells, one of the root causes of aging), and therapies to reprogram cells to regenerate and rejuvenate tissues. These interventions are working fine in animals, extending their period of health and thus extending their lifespan (lifespan extended in worms 10 times, in flies 2 times, in mice by ~30%), and reversal of age-related diseases was also observed. Some of these interventions are already in human clinical trials all around the globe. We are listing some of them in our Rejuvenation Roadmap, feel free to check it out.

    We are currently going through a transition towards the possibility to completely cure age-related diseases and other chronic diseases, which will make people truly healthy, so why to lower the standard of health instead of using it as a goal, is unclear.

  • Wonderful!
    But how about an even more expansive definition of personal health as whatever the individual deems it to be? That could include a person who chooses NOT to manage their chronic illness…hemoglobin A1c be damned! That could free health care professionals from the tyranny of quality metrics that derive from the WHO definition of health.
    Now public health would still be important. My “right” to bear the risk of influenza or lung cancer needs to be counterbalanced by my neighbors’ similar right to avoid such risks, so vaccination requirements and public smoking bans make sense and should be funded.

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