Revisiting the question of “why health?”

We aspire to be healthy so that we can live full lives.

Let’s talk about health.

How we think about health is often wrong. In fact, we often do not think about health at all when we think we are thinking about health. What we think about is disease. We worry if we have a pain somewhere. We wonder if we are maybe diabetic. We brood about the possible causes of a chronic itch. We ask ourselves, “Did I just pull a muscle?” We may believe this constitutes thinking about health. But it does not. We are, in fact, thinking about the absence of health. We are thinking about disease. This mis-think extends to the public conversation. When health is written about in the media, it is more often than not in writing about disease.

I am sometimes asked to comment in the media on issues of consequence for health. Typically, I am asked to look at the world through the lens of disease—of how to avoid or treat sickness. I am asked about a particular new virus, about diseases of the heart or of other organs. This impulse to seek this perspective is understandable. There are few experiences in life more all-consuming than that of disease. When we are sick, our affliction is often all we can think about, and this is the case at both the individual and societal level. When we are in pain, when our body does not work as it should, it can become the central fact of our lives.

It is therefore truly hard to look past the reality of disease and the urgency of treating afflictions when we talk about health.  And commensurately, it is seldom that we think about health when we are healthy. It is uncommon to hear one say, for example, that one is in “chronic good health,” even as we often hear about “chronic poor health.”

Yet the idea that health is not disease is not new. It is embedded in the preamble to the constitution of the World Health Organization, which defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This reminds us that health is more than sickness, and that supporting health is more than just creating better treatments for disease. Supporting health means creating the conditions for everyone to achieve “a state of complete physical, mental and social well-being.” The implications of this are that we must build a world where all can access the conditions that support this level of wellbeing. This task starts with having conversations about health that include the full range of issues that are relevant to the creation of such a world. Helping to advance these conversations has been a core focus of my writing and speaking throughout my career and is a central raison d'être of this newsletter.

But I am not here writing to repeat the idea that health is not merely the absence of disease. There are many who have written extensively and well about this. I am here to pose the question of “why health?”—why do we embrace health as a good worth pursuing? The post-COVID moment has created space for a reevaluation of first principles. How we answer the question can help shape our priorities and practices in the years ahead.

Health is, at core, a means to an end. That end is, as I have previously written, our collective ability to live rich, full lives. This means that the pursuit of health should always be subordinate to the fundamentals of human life. When we find ourselves considering a measure to support health that may become an impediment to populations living rich, full lives, we risk straying from our field’s core purpose. Public health should be about what Teju Cole called “the incontestable fundamentals of a person: pleasure, sorrow, love, humor, and grief, and the complexity of the interior landscape that sustains those feelings.” In the academic space, this focus has often animated discussion about how we define fundamental human rights. As we have expanded this definition, we have become more closely aligned with a philosophy of health which prioritizes what health is really for: the living of a full life. In the years since World War II, we have begun to embrace a definition of rights which includes rights to housing, healthcare, freedom from fear and want, and the capacity to enjoy access to the resources that support a good life in a world without inequities. In helping to shape this evolving definition, public health can play a key role in ensuring that our work is inextricably tied to a definition of health which supports a good life for all.

This is why I have throughout my career regarded engaging with the public conversation about health as a central step towards a healthier world. I write and speak to try to nudge our definition of health towards being one that is fundamentally about creating space for people to experience life in all its pleasure, sorrow, love, humor, and grief. I include sorrow and grief because for public health to be fully mature in its philosophy and fully effective in its work, it needs to understand that, when we see health as a means to the end of living a full life, we accept that this life will have rainy days as well as sunny ones, pleasure as well as pain, and it should not be the business of our field to try to undo this reality. When we try to create the conditions of total safety, a world completely free of disease, we risk embracing approaches which ultimately undermine our capacity to live full lives. Instead, we should take reasonable steps to safeguard health while taking care that these steps never run counter to the fundamental goal of health. We should want everyone to have space to experience the fullness of their humanity, however they choose to do so, in as dignified a manner as possible. This goal should not be incidental to the work of public health, it should be a first principle of our field, the public health equivalent of “first do no harm.”

I realize that this realignment has significant implications for how we pursue our work in this post-war moment. These implications are many, but, to my thinking, three key points stand out, which I will try to distill here.

First, when we recognize that health is subordinate to our shared humanity it means that we should not be doing everything just for the sake of health. We need to be judicious in what we are willing to do to create health and be clear that there are some steps we are not willing to take. I have previously written about a concept, introduced to me by my colleague George Annas, of a human zoo. None of us want to live in a human zoo, where we might be well looked after, tended to, fed, exercised, but constrained. This is critical, because it means that we should have limits to what we are willing to do to protect health. It means that, for example, a zero-COVID approach to the pandemic should never have been tolerated in the name of public health, and that we should be clear about the unacceptability of such zero-sum steps.

Second, we need to accept that people have the autonomy to live how they wish to live. We are not promoting health so that people can always make healthy choices. We are promoting health so people can live how they want to, have the opportunities and access to healthy choices.  However—and this is where it gets difficult—if that means people sometimes make unhealthy choices, we need to accept that. This is complicated because part of our work is indeed to persuade as many people as possible that making healthy choices is the best way to support health and, thus, to live a rich, full life. I am not saying that we should not do this, that we should stop saying, for example, that skydiving may not be the healthiest of choices. What I am saying is that we need to allow that many may choose to ignore our advice and keep skydiving, and this is, on some level, OK. In the face of this reality, it is on us to embrace a healthy paternalism without tipping into heavy-handed overreach.

Third, an enormous part of what we do needs to be centered on the multiplicity of human expressions and potentials. We need to prioritize creating opportunities for people living with disease so they can realize their potential. This requires an acknowledgment of our limits in generating health. No matter how effective we in public health are, there is no getting around the reality that human beings will always age, sicken, and die. That elevates ensuring that those who are older can continue to live with dignity, that persons with disabilities have access to the resources they need to be healthy and that we maximize the potential of these populations. It means grappling with the messy tradeoffs involved in investing in access for people living with disabilities when this comes at the expense, sometimes, of investing in treatments that may yield benefits in the long-term. Most of all, this means keeping front and center in our thinking an awareness that our goal is to support the opportunity for everyone to live full lives, never letting our actions get in the way of this aspiration.

These implications reflect the foundational importance of how we think about the question “why health?” I recognize that my perspective on answering this question may invite disagreement and this is to be welcomed. Defining the philosophical foundations of any field calls for robust debate. It is better to disagree about these foundations than to leave them unconsidered and risk our efforts being unmoored from the well-thought-out first principles that anchor serious work. This newsletter will continue to engage in the coming months with the conversations that help advance a new practical philosophy of health, one shaped by the lessons of the recent past and responsive to the needs of the present. Topics will include how we can create structures that allow all people to flourish as they choose to, fostering respect for autonomy and human rights, the obligation for humility and compassion, and creating pathways to dignity for all lives. At core, such conversations all point back to the question: why health? Reintroducing this question today is meant as a grounding, perhaps a provocation, for the conversations to follow, a centering of future topics in what is fundamental to our work. Thank you to all who have been, and continue to be, part of these conversations.

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Also this week.

I had the privilege of co-editing the special centennial issue of The Milbank Quarterly with Drs Alan B. Cohen and Paula Lantz.