An imperfect health

On creating a world that allows all of us to live healthy lives, no matter how we may define doing so.

Public health is fundamentally a story. My new book, Within Reason: A Liberal Public Health for an Illiberal Time, is about how we can ensure that story is guided by our values. Here is a reading from the book. In this segment I discuss how I wrote the book as a call for us to return to the small-l liberal principles that have long been at the heart of public health. Thank you for supporting the ideas in The Healthiest Goldfish, and those in the book. Within Reason will be available December 1, and can be pre-ordered here.

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In writing these essays, and in much of my past writing, I often invoke health. In addition to essays and articles, I have written several books, all of which are centrally concerned with creating a healthier world. Two of my more recent books, Healthier: Fifty Thoughts on the Foundations of Population Health and Well: What We Need to Talk About When We Talk About Health, are efforts to help shape a vision of health that can get us closer to a radically healthier world. The pursuit of such a vision is informed by the assumption that we have, collectively, a shared understanding of what health is: I know what it is to be healthy and so do you. Our goal is to help each other get there by creating a world that is better, healthier.

And yet, as I think about health in a post-war context, I have found myself wondering if perhaps our understanding of health—of what health fundamentally is—is not as philosophically useful to the business of generating a healthier world as it might be. Could it be that what we mean by health is not quite what we should be aspiring to in our pursuit of such a world? Could our present notion of health be, in fact, a necessary but insufficient condition for creating a healthier future? These questions suggest there may indeed be space for thinking more expansively about what health is and what our pursuit of health should entail in this moment.

In my own thinking and writing about health I have often found myself leaning on the preamble to the WHO constitution, which says, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” In truth, I have referred to this quote so often that it can feel a bit hackneyed at times. But I continue to lean on it because I think it reflects an accurate understanding of health. Our world is not healthy if it can treat a range of diseases but cannot prevent them. It is not healthy if it invests in healthcare alone while neglecting the foundational drivers of health.

This understanding of health, which is broadly shared in the field of public health, has allowed me to broaden my lens in my engagement with the drivers of health, recognizing that there can be no health without a context that supports it. For a long time, this view of health seemed sufficiently comprehensive as a philosophical underpinning for an effective pursuit of health. Within this framework, we can clearly see how health depends on creating a world where everyone can access the resources that support health, not just the treatments that banish disease once we get sick. We see how health depends on creating clean air and water, good schools, safe neighborhoods, social networks that reinforce healthy behavioral norms, and an economy that supports opportunity for all. This focus also aligns with an understanding that health is a means to an end—that what health is ultimately for is to enable the living of rich, full lives. In a previous essay, I talked about why I think health should matter, namely that health should matter not for its own sake, but to help us live good lives. That shifts the focus away from an idea of health as a purely biological construct to locating it within a larger social framework, in which we are healthy so we can spend more and better time with the people around us, whose presence adds meaning to our lives.

I still believe this definition of health—the prevention of disease as a means of enabling the living of a full life—is a good one, grounding our pursuit of health in addressing the structures that create a healthier world while keeping us focused, always, on why we are doing what we are doing. However, as I have reflected on this definition of health in the post-war moment we are in, I have come to feel like it might be clarified further. In asking the question “Why health?” it seems to me useful to also ask “What kind of health do we need in order to live the kind of lives we want to live?”

This is where the definition of health wobbles. Because you and I may instinctively think that to live life fully we need, say, a healthy body, energy to leap over hedges, mental clarity to read long novels, and visual acuity to watch movies. That is health, and the conditions that support our capacity to be healthy in this way constitute the conditions that shape a healthy world. But what if our visions for what enables a fully lived life differ? What if your vision for such a life does not emphasize physical ability or mental energy, but is instead concerned with other factors? Then, health—the means to this differently lived life—can be construed very differently indeed. What one person may regard as a state of perfect health that supports a perfect life, another may see as imperfection, their own aspirations lying elsewhere.

When I ponder this approach to health, and the many varieties of health that may exist within the basic framework for health I have long accepted, the question naturally emerges of what is to be done to calibrate our pursuit of health to support health in all its varieties. This reflects an “outcome-driven approach,” one that starts from the goal—living a good life however we might define it—and works backwards to the means—health—to that goal. Towards this goal, three thoughts emerge that shape, or at least challenge, my thinking about what health is and how we might get it, as we look to advance approaches that maximize health for all, supporting each of our individual visions of what health means to us.

First, our view of what living a good, full life means, and our capacity to achieve this aspiration, is determined to a significant degree by the world in which we live. It is our present context, rather than any sort of universal law, that decides whether our individual attributes constitute a barrier to “perfect” health, or whether they are simply inconveniences, easily dealt with. For example, I am Maltese, born and raised on a small Mediterranean island. And yet, I get terribly seasick at essentially the moment I step on a boat. I have no doubt that were I born a few hundred years earlier I would have been weeded quickly out of the family as utterly useless in a culture that depended on fishing and all manner of seafaring for its survival. Clearly, inability to travel via water would be a substantially limiting factor at that time for my ability to live a fully realized life. Having the good fortune to live when and where I do, my seasickness is immaterial to my life—I just avoid boats, and all is well. What would have been regarded at one time as a significant imperfection, then, becomes, in the present moment, a mere quirk.

Once we understand that the ability to live a full life is determined by the context in which we live, our notion of what is healthy changes. Hence, I am not so sure any more that we can even define health without recognizing that this definition is, in large part, determined by the world we build. We can choose to build a world where our definition of health limits fewer people in their efforts to live the lives they want. This has implications, for example, for our efforts to create a better world for people who live with disability. While we have taken steps to make life easier for this population, we still live in a world where much of what we consider “disability” acts as a barrier to many of the pursuits we define as core to a full life. What if we were to create a world that is as different, better, for this population? As I have written previously, creating a world “where disability is not merely accommodated but uplifted” could serve as an example of how, by changing context, we can radically change the implications of what we might previously have defined as imperfect health. 

Second, when we recognize that health, then, is more of a social construct than it is a biological absolute, there is an enormously slippery slope that can lead to a paternalism bred from good intentions that describes what health is based on the social constructs of the moment. We may, for example, find ourselves, in our efforts to make the world better for populations whose context imposes limits on their health, inadvertently reinforcing the health gaps created by these limits. Imagine, for example, we live in Waterworld, where my seasickness is a serious limit on my capacity to live a good life. It is possible to imagine some well-meaning citizens of that world doing all they can to create novel ways for me to traverse Waterworld despite my aversion. Yet in working towards these accommodations, they are distracted from the possibility that there may somewhere be dry land (I realize now I am perhaps borrowing from the 1995 Kevin Costner film), a place where my seasickness would not be an issue. This is not to say that we should not work towards accommodations for all of us who may need them, but we should not do so at the expense of imagining new contexts for health, where what may function as imperfections in the present moment no longer need interfere with the pursuit of a full life. It then becomes incumbent on us to create a world that opens up space for as many people as possible to be “healthy” because they can live their lives more fully, in ways that align with their individual visions for what health means.

Third, all of this comes down to the values that animate what we do, what we prioritize and why. Perhaps what is at issue is not so much our capacity to be healthier in some sort of one-size-fits-all way as it is what it will take for people to live their lives in ways that align with their personal vision of health. If so, we need to establish values around what this means for us, collectively. How can we create a world which supports the health of all, generally, while supporting the health of you and I, specifically, in keeping with our personal visions for a healthy life? I have argued before, and I reassert here, that what should rise to the top of our priority list is ensuring that everyone can live a life with dignity, and that everyone has opportunities to realize their potential. The world should be structured so that everyone can lead full, dignified lives and also so that everyone can do all they wish to do, everything that means health for them. In looking ahead to a new, practical philosophy of health, there is utility in looking back, in seeing how the values that have supported progress in the past can support it in the future as we embrace new definitions of what it is to be healthy and what it is to create a healthier world. Dignity, respect, autonomy for all—these are the values that can help us create a context where an imperfect world no longer means imperfect health.

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Also this week.

If of interest, Highbridge Audio is offering a 60% discount on the audiobook version of my book, Well: What We Need to Talk About When We Talk About Health.

New in JAMA with Salma Abdalla, Data to Improve Global Health Equity—Key Challenges.