Elementary concepts of medicine: II. Health, health fields, public health

Medicine, its set of specialties, is a particular set of so-called health fields. Thus, medicine could be defined with aggregate of health fields as its proximate genus (with pursuit of gnosis and engagement in gnosis-based teaching of the client as the specific difference). In exploring the specifically medical concept of health, the natural point of departure might be its definition (as cited in Last 1995) in the preamble of the 1948 constitution of the World Health Organization: 'A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity'. That this indeed stands for a definition of health from the expressly medical vantage is averred by its repetition, essentially verbatim, as the definition of health in a current, eminent dictionary of medicine (Dorland 1994). The latter source merely substitutes 'optimal' for the original 'complete' and puts a comma after 'well-being'. As specification of something that would be too narrow a conception of health does not belong in its definition, this medical dictionary definition really should be expressed, more succinctly and more correctly, as: A state of optimal physical, mental and social well-being. (Definition A) Another equally eminent, current dictionary of medicine (Stedman 1995) gives a tripartite, 83-word definition. Application of Occam's razor to this one leads to: A state of physical and mental integrity and freedom from the risk of losing this. (Definition B) That these two contemporary and authoritative definitions of health as a medical concept are not interchangeable implies that the concept of health remains incompletely developed in medicine, and we (and others) therefore need to try and develop it further. For a start in this, we propose elimination of 'social' from definition A. From the medical vantage, we do not regard the lovelorn, or even the love-sick social state as inconsistent with health, nor lack of social skills, nor even solitary confinement, however much any of these may take away from social well-being. In this respect we side with definition B. Then, what about the idea, common and manifest in both of those definitions, that the medical concept of health subsumes mental as well as physical health? To us, the essence of mental well-being, mental health in the psychological meaning of 'health', is happiness. All of human endeavours represent striving for personal happiness (von Mises 1966, pp. 14–15), use of medical care – inherently concerned with the body rather than the mind – being just one of the multitude of elements in this universal and fundamental human pursuit. By no means are we physicians all–purpose counsellors for this multifaceted striving; we are professionally concerned with only physical determinants of happiness, and this in the particular meaning of bodily, somatic, determinants. Medically, thus, the referent of health we take to be somatic, singularly. Let B stand for the body, the realm of the somatic, and M for the mind, the realm of the mental. These two interact: the body's condition greatly influences that of the mind, B → M; and to a lesser extent the converse is also the case, M → B. But regardless, B is the realm of the physician (cf. medicine as 'physic'), and M is that of the psychologist and also of the educator and the cleric among others. Indeed, modern psychiatry increasingly is the specialty dealing with those abnormal somatic states that have mainly mental manifestations, and thus with pharmacotherapy in lieu of psychotherapy. Psychological counselling increasingly is for the clinical psychologist to provide. With both 'social' and 'mental' removed from these two definitions, what about the 'well-being' in definition A? This term properly refers to feeling well, medically a matter of freedom from patient-evident manifestations of ill-health (somatic) rather than from ill-health itself. Well-being even in this medical meaning is not definitional to health, as it is not unique to health. After all, latent illness is a well-established concept of medicine; and surely, when a person has a serious illness still in its latent stage, this person, while still enjoying physical (somatic) well-being, is not healthy, medically speaking. Before addressing the 'integrity' alternative to well-being, what about the 'risk' note in definition B? Driving dangerously represents heightened risk of losing bodily integrity; but so long as this outcome is avoided, health remains uncompromised by this behaviour. Certain genotypes represent heightened risks of particular illnesses; but so long as the heightened-risk illnesses have not materialized, the genetic anomalies have not taken away from health. Risk of losing bodily integrity, whether recognized or not, is inherent in the human condition and thus not inconsistent with health, so long as we allow for the actual existence of health; and we do. For these reasons, we believe the risk note in definition B must go. All of this leads us to reduce these two medical dictionary definitions of health to this single one: A state of somatic integrity. (Definition C) But this, even, requires critical examination. Were the concept of health inherently to be that of overall health, this singular physical state would call for the definite article. But in point of fact, there are, medically, many component 'healths' as well, cerebral (distinct from mental) health, for example. Thus, the indefinite article is apposite; 'any' would be a suitable alternative. 'Somatic integrity' in the context of health properly means, in the main at least, presence of all normal parts of the body – thereby saying little or nothing about the state of those parts, or about possible presence of parts that do not belong in a normal body. Thus, somatic integrity is not quite the medical concept of health. After all of this, the setting is ready for what we see as the simple truth: Medically, health is the absence of ill-health, illness (somatic) – general health the absence of any illness, specific health the absence of illness in a particular part of the body. (Definition D) When saying, as is commonplace, that medical fields are health fields, the idea is not that medicine is concerned with absence of illness, in the main at least. Rather, the idea is that illness is a condition of health (in the sense of absence thereof), so that medical fields as fields of illness are thereby – as a matter of preferred, euphemistic expression – fields of health. As for terms such as 'occupational health', the avoidance of 'medicine', we take it, is aimed at avoidance of the implication that at issue is a field for physicians only, occupational medicine being the medical – physicians'– specialty within the multidisciplinary field of occupational health. The US Public Health Service ('health' again) recently sponsored a book entitled Cost-effectiveness in Health and Medicine (Gold et al. 1996), implying that the fields of medicine are distinct from those of health. Never defining medicine or health, the editors contrast clinical medicine with public health (as to their respective types of intervention; pp. xxii–xxiii). This is commonplace but, in our view, unjustifiable. We contrast clinical medicine with community medicine, or clinical (individual-oriented) health with community (population-oriented) health. The latter inherently is something in the public sector; it is, by its very nature, 'public' health. Public health as an aggregate of health fields we take to concern those aspects of health care that are societal (public) in nature, upon the advent of national health insurance, overwhelmingly, societal aspects of clinical medicine.

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