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Health and illness: the definition of the World Health Organization

Derek Yach It is a great privilege to have the opportunity to discuss WHO's views on health and illness at the start of this most important symposium. It comes at the beginning of a year during which the World Health Organization will celebrate its 50th Anniversary, and also in a year in which a new global health policy, Health for All in the 21 st Century [8], is scheduled to be adopted by the World Health Assembly. As 1 will indicate, the theme of your symposium is both timely and relevant to the content and focus of the new policy. Furthermore, the selection of the topic you have given me, namely a discussion on the definition of health and illness, is highly appropriate for Davos, A century ago, people with tuberculosis from all over the world sought cure and help in the clean mountain air of Davos and surrounding towns. Now, they seek more than the cure of a single disease, but gather on an annual basis to improve the economic welfare of the world's people, thus contributing to improved global health. I will outline the origins of the definition of health that is used in the WHO Constitution-, discuss common difficulties with the definition of health; highlight progress made towards the attainment of health; and end with some comments on the future challenges that we face in health matters for thenext century. Finally, 1 will outline WHO's policy response to these challenges.

Origins of the definition

Individuals and societies have long considered various definitions of health. In doing so, they usually fell into three areas. The first, the perception of health, is either seen as a subjective or objective phenomenon, and in terms of whether it extends beyond the physical domain. The second includes the means of improving and maintaining health. The third, considers the value and aim of health, Le. how it allows one to function. These three areas are usually considered together in historical and contemporary definitions. It has long been recognized that there is a close interaction between a healthy mind and a healthy body. Furthermore, health was considered in antiquity a beneficial asset and one that required action by the individual to preserve it. Thus, in the Hippocratic writings it is said that "a wise man ought to realize that health is his most valuable possession and learn to treat his illnesses by his own judgement" [2]. During classical times and all through the middle ages, the struggle for survival, a struggle that aimed to overcome common epidemics, childhood infections and the hazards of childbirth, all limited populations' abilities to improve their physical health. Under such conditions, strong emphasis was given to mental, social and spiritual dimensions of health. By the end of the eighteenth century, public health and medical advances had laid the basis for people to believe that a long life could be obtained through societal actions, as well as through the actions of individuals. In fact, at the turn of the last century it was expected that all the

challenges to health and disease would be conquered in a short period of time. Midway through the twentieth century, and with the start of the use of antibiotics and vaccines, this belief endured and remained in some ways an impediment to the full realization of a broader definition of health. Prior to the Second World War, Sigerist, a well known public health professional, expressed the view that "health is, therefore, not simply the absence of disease; it is something positive, a joyful attitude to life, and a cheerful acceptance of the responsibilities that life puts upon the individual... A healthy individual is a man who is well balanced bodily and mentally, and well adjusted to his physical and social environment" [3]. Development of the notion of social responsibility for health and the duty of individuals for the care of their health was espoused by Dr Andrija Stampar, who was to become President of the First World Health Assembly of WHO. It was he who played a crucial role in drafting the definition of health that was to be incorporated into the first paragraph of the preamble to the WHO Constitution and subsequently into the International Covenant on Economic, Social and Cultural Rights. Thus it was that over half a century ago, the founders of the World Health Organization defined health as "a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity". The Constitution further recognized "the enjoyment of the highest attainable standard of health ... as one of the fundamental rights of every human being" [4]. This "right to health", as it became expressed in an abbreviated version in many subsequent documents, includes the right to adequate food, water, clothing, housing, health care, education, security in the event of unemployment, sickness, disability, old age or lack of livelihood in circumstances beyond an individual's control. Greater emphasis in the definition to equity and social justice was given when the Thirtieth World Health Assembly decided in 1977 that the main social targets of governments and WHO in the coming decades should be "the attainment of all citizens of the world by the year 2000 of a level of health that would permit them to lead socially and economically productive lives" [5]. This statement is important in that it specifies both what level of health is needed and what will be accomplished at that level.

Common difficulties with a definition

Over the decades, there have been many criticisms of the definition of health and of the shorthand version of "health as a human right". Some considered the definition too inclusive and should focus rather on the physical domain of health, the rationale being that health and its achievement was best left to health professionals and to the application of specific health and medical interventions. There are others who felt the definition excluded important dimensions, such as the spiritual and ethical dimensions of health. I will return to this later. The third concern was that many felt that it was unrealistic to believe that all could be healthy. Protagonists of this view point out that there are genetic impediments to the attainment of health by all; that there are limits to the availability of resources available to ensure that all can attain the highest level of

health; and that our scientific knowledge remains incomplete with regard to the true determinants of health and effectiveness of interventions. Additional difficulties follow from these definitions and relate to the problem of measuring health and implementing programmes that would improve the health of individuals and populations. The physical dimension of health could be measured in terms of life expectancy, the infant mortality rate and other relatively objective measures. However, with advances in technology, particularly in the fields of imaging and genetic screening, we now recognize that almost all of the population either have an actual or potential predisposition to some future disease. Over the last few decades, psychiatrists and psychologists have made considerable progress in quantifying and defining mental disease. Progress has been less substantial in defining mental health. Certainly, the presence of organic brain disease or major metabolic abnormalities leading to clearly identifiable mental disease are now routinely diagnosed and treated. Greater difficulties are experienced in measuring the social aspects of health. In recent years, attention has been given to the notion of social capital, a term used to acknowledge the importance of formal and informal networks that individuals, families, and communities depend upon if they are to function optimally. Furthermore, inequalities in social and economic status can be regarded as impediments to the attainment of the full state of social health. Measuring the spiritual dimension of health is perhaps the most complex. 1 have no doubt that you would all agree that attendance at places of worship is neither a necessary, nor a sufficient condition for the full achievement of spiritual health. At the other extreme, the absence of crime and violence and the presence of peace and stability in a community where love prevails between families and neighbours may be more relevant, but is not easy to measure. WHO has attempted to resolve some of these measurement issues by identifying specific targets and indicators [6] that in themselves are merely proxies of certain of the dimensions of health. Furthermore, by defining health in terms of one's ability to work productively and participate fully in social life, a greater degree of operationalization is attainable. We need to recognize that health is everyone's business and that the ultimate responsibility for its attainment is shared between individuals, families, communities, governments at all levels and intergovernmental agencies. This is important to consider when we assess the degree of progress made towards health for all.

Recent progress in attaining health for all

Over the past 50 years, the world has witnessed unprecedented gains in health as measured in physical terms. For example, life expectancy at birth has increased from 46 years in the 1950s to 65 years in 1995. Globally, there has been a substantial decline in the infant mortality rate, maternal deaths have remained unacceptably common, the level of childhood immunization has increased dramatically and access to primary health care, including water and sanitation, continues to improve, albeit at a slower rate in the last decade than in previous decades [7].

Taken together, many physical dimensions of health can be said to have improved substantially, with people living longer and, in general, experiencing lower levels of illhealth in childhood and early adulthood. Concurrent with these improvements in life expectancy have come profound demographic and epidemiological changes that are now characterized by a rapid increase in the proportion of people living to over 70 years of age, a marked increase in noncommunicable diseases, particularly arising as a result of increased tobacco use and increased consumption of high-fat foods. Simultaneously, poverty-related infectious diseases remain with us, and new and emerging forms of infectious diseases are unfortunately appearing at a regular rate. They provide a continued challenge to epidemiologists and public health professionals. Levels of injuries and violence remain high and are increasing in certain communities. Compared to 50 years ago, however, I would regard progress in improving the physical dimensions of health as being very good to excellent. With regard to the mental dimensions of health, we have seen a combination of urbanization, ageing, and new sources of stress lead to increased identification of mental ill-health and objective evidence of an increase in certain problems, such as unipolar major depression, particularly among women. The causes for this increase remain unclear and are probably related to the complexity of social change. The good news has been that progress has been made in the early identification and treatment of mental illness, albeit of an individual rather than at a societal level. Progress, therefore, in terms of improving mental health could be classified as moderate. The social dimension of health is exemplified by the high levels of poverty that still persist and have increased in many parts of the world. There are 1.3 billion people living in absolute poverty [8]. Further levels of inequalities in wealth and health are increasing in many societies, be they advanced industrialized European countries or poorer developing countries. This means that progress in achieving the social dimensions of health remains a long way off. Furthermore, rapid urbanization, migration and recent conflicts on most continents further contribute to social disintegration and instability. We can only regard progress here as extremely limited. Finally, with regard to the spiritual dimension of health, there have been fears in recent years that new cults and ethnic conflicts are likely to exacerbate social instability. We can only observe that there is more uncertainty in advanced industrialized countries about the future, that with ageing, populations remain strongly committed to formal religions and that, thankfully, cults remain on the periphery rather than becoming mainstream. We have no direct means of knowing whether the spiritual health of populations has worsened or improved.

Future challenges and WHO's new policies

In developing the new global health policy, WHO sought to obtain the views of the widest possible range of participants, including Member States, nongovernmental organizations, the private sector, the United Nations and other international bodies, as well as academic and research communities. What emerged through the consultations was that health for all remains an enduring vision. It seeks to create the conditions where people universally and throughout their lives, will have the opportunity to reach and maintain that highest attainable level of health as a

fundamental human right. lt is a vision that recognizes the oneness of humanity and therefore the need to promote health and to alleviate ill-health and suffering universally and in the spirit of solidarity. Health-for-all values underpin and will be incorporated into all aspects of health policy. The vision is based on the following key values: 1. Recognition of the highest attainable standard of health as a fundamental right 2. Continued and strengthened application of ethics to health policy, research and service provision 3. Implementation of equity-orientated policies 4. Incorporation of a gender perspective into health policies and strategies. What is new in the policy, or has been made more explicit over time, are issues related to the spiritual dimension, to ethics and to gender. The new policy, for example, acknowledges "the uniqueness of each person and the need to respond to each individual's spiritual quest for meaning, purpose and belonging" [8a]. At the same time, health for all is recognized as a societal response that acknowledges unity and diversity. It is our common humanity and responsibility for current and future generations that demands we embrace health-for-all values. Importantly, our Executive Board adopted a resolution early in 1998 calling on the World Health Assembly in May of the same year to change the WHO constitution to include the spiritual dimension of health. It is the support for universal values that are at the core of all major religions that links us together. Common to that core is the injunction expressed clearly by all major religions that "we should not do unto others as we would not have them do unto us". This has public health significance in that it implies the need for collective action, the basis for effective infectiousdisease control, for reducing the levels of injuries and violence and stopping the spread of products that lead to increased noncommunicable diseases. The new global health policy recognizes that a strong ethical framework based on respect for individual choice, personal autonomy and avoidance of harm must be applied to individual and social aspects of health care and to research. In spelling out a strong and clear message about the importance of ethics in the new global health policy, WHO builds upon the historical evolution of ethics that has passed through several phases. Initially, the focus was on the conduct of health professionals as they provide compassionate care, as they respect individual choice, confidentiality and autonomy, as they avoid harm and appreciate others' values and needs. The policy goes further than considering the conduct of health professionals, to focus on equity and social justice in access to and utilization of health care, and to ensuring that quality in health systems and services is assessed and promoted, Furthermore, it takes account of contemporary and expected rapid future changes in science, research and technology. Thus, it calls for us to monitor and update ethical norms for research and, most importantly, to anticipate ethical implications of advances in science and technology for health. This is as important with regards to advances in genetic engineering and maintaining the integrity of the human genome as it is in many other areas of technology development for health. Finally, the ethical component also acknowledges the need to focus on the intergenerational aspects of ethics, thus taking health policy closer to policies related to environmental sustainability.

We recognize in the new policy that a gender perspective is vital to the development and implementation of equitable and effective health policies and strategies. Such a perspective will lead to a better understanding of the factors that influence the health of women and men. The "Health for All" policy not only provides guidance with regard to the meaning and importance of the definitions of health, but also gives explicit emphasis to the need to move from policy to action. In doing so, we recognize how important it will be to harness the will and action of diverse sectors and partners for health at all levels. Governance for health goes beyond government or the management of services. It is the system through which society organizes and manages the affairs of these sectors in order to achieve the goals of health for all. Only with the collaboration of the many interested sectors that have an impact on health can the promise of the vision be realized. This is particularly important since we recognize that the roots of good health and the causes of much ill-health lie outside the health services. This is not to say that the health systems and services, and the many health professionals within them, do not have a vital role to play in the attainment of health for all. Rather the contrary is true. It is the health professionals who need to play an even stronger and leading role in ensuring that health for all becomes a reality. It is, after all, you who feel the consequences of the failure of policies and strategies in other sectors. Way back in 1790, Johann Peter Frank in Germany argued "that health and well-being could only be obtained where there was freedom from want and social deprivation" [1]. Our goal will be to ensure that through an exploration of ethics in health we can identify the means of ensuring that health and well-being can be advanced through the sustained and collaborative action of all of us. In conclusion, in the new global health policy, the role of WHO is made explicit. WHO, as a representative body of its 191 Members States throughout the world, recognizes that it has a unique mandate and responsibility to guide all partners involved in global governance of health towards the attainment of health for all. lt will do so by promoting international collective action that benefits all countries, and by responding to global threats to health. Furthermore, it will provide technical cooperation to support health development in countries and to protect the health of vulnerable and poor communities and countries. In doing so, WHO, which consists of all of us, hopes that by the 2020s we will have made substantially more progress in attaining the fullest definition of health for all as understood by the Constitution and through the words of the new policy, "Health for All in the 21 st Century".

[1] Frank JP (1790) The People's misery, mother of diseases. (An address, delivered in 1790 by Johann Peter Frank, translated from the Latin with an introduction by Henry E. Sigerist) Baltimore, s.n., 1941
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Rosen GA (1976) A history of public health. MD Publications, New York

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Sigerist HR (1941) Medicine and human welfare. Yale University Press, New Haven
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World Health Organization (1948) Constitution. World Health Organization, Geneva

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World Health Organization (1977) Resolution WHA40.43 - Technical Cooperation. World Health Organization, Geneva, May, 1977
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World Health Organization (1985) Targets for Health for All: targets in support of the European strategy for Health for All. World Health Organization Regional Office for Europe, Copenhagen
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World Health Organization (1998) The World Health Report 1998. Life in the 21 st Century: a vision for all. World Health Organization, Geneva
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World Health Organization (1998) Health for All in the Twenty-first Century. Document A51/5, World Health Organization, Geneva (During the 5 Ist May 1998 World Health Assembly, the policy was recognized "as a framework for the development of future policy")
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Derek Yach World Health Organization 20 av. Appia CH- 1211 Geneva 27