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Public Health Definition of Health
by
Lawrence W. Green

Introduction

The definition of health has evolved with the changing conditions of societies, with the changing technologies for identifying abnormalities at finer tissue and molecular levels and at earlier stages of disease, and with the redefinition of conditions as health problems that were previously considered within the range of normality or at least outside the realm of medicine, sickness, and health. Some refer to these drifts in the definition of health as the medicalization of everything organic and emotional that bothers people; some worry that societies are letting technology define health for them. For public health, the need exists to define health with some consensus and concreteness for the purpose of measuring the health of populations. Measuring the health of populations requires the collection of data on large numbers of people, at considerable expense, to monitor trends in population health, detect outbreaks of ill health, trace causes or sources of such outbreaks or epidemics, and to evaluate the progress and achievements of programs directed at protecting or promoting health.

General Overviews

The first recorded break from divine notions of health requiring prayers and sacrifices to the gods is variously attributed to Hippocrates or the Hippocratic School of medicine on the Mediterranean island of Cos in the centuries surrounding the Christian era. Although the name Hippocrates is more frequently associated with medicine, the approach to health associated with Hippocratic teaching had a decidedly public health emphasis on environmental sanitation, personal hygiene, and nutrition, as discussed in Üstün and Jakob 2005. Debates over the definition of health have ranged from the strictly empirical, for which the Hippocratic school of medicine is the usual touchstone, to the idealistic in World Health Organization 1948; to humanistic philosophical critiques of the pursuit of technological fixes for health in Dubos 1959; to psychological in Justice 1987, Kessener 1982, and Maslow 1968, to cultural in Airhihenbuwa 1995; to patient self-determination and autonomy as central values in defining health for practitioners in Young and Hayes 2002; to sociopolitical national policy debates in O’Neill, et al. 2007.

  • Airhihenbuwa, Collins. 1995. Health and culture: Beyond the Western paradigm. Thousand Oaks, CA: SAGE.

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    Extends the postmodern, postcolonial, feminist, and anthropological discourses and theories on health to an examination of health as “cultural production.” Rather than Western social scientists speaking about and for people of other cultures, it incorporates the voices of those cultures. Religion, magic, and superstition and their resulting concepts of health are based in rationality that can best be understood from the locally interpreted historical experience of those cultures.

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  • Dubos, René. 1959. Mirage of health. New York: Harper & Row.

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    In his humanist challenge to the technological view that health can be achieved by technological means or by individuals acting alone, Dubos defines health as “the expression of the extent to which the individual and the social body maintain in readiness the resources required to meet the exigencies of the future.”

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  • Justice, Blair. 1987. Who gets sick: Thinking and health. Houston, TX: Peak Press.

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    One of the first books to compile and weave together the varied influences of pessimistic thinking, love, faith, attitudes, beliefs, moods, feelings of helplessness, social ties, and thoughts on health, thereby redefining the scope of definitions of health in the growing tradition of mind-body relationships. Chapter titles include “Germs and Stress,” “Neurotransmitters,” “Coping,” “Vulnerability,” and “Self-repair.”

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  • Kessener, A. W. 1982. Gezondheidszorg, fictie of realiteit? Medisch Contact 37:335–338.

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    This paper on “Health Care: Fiction or Reality” staked out the more extreme nonmedical position that personal perception of well-being should be what defines health, not biological opposites or absences of disease or disability. If people perceive themselves as healthy, they can be said to be healthy.

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  • Maslow, Abraham H. 1968. Towards a psychology of being. New York: Van Nostrand Reinhold.

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    Maslow’s hierarchy of individual needs has been widely used as a way of interpreting the World Health Organization’s definition of health as a state of physical, social, and mental wellbeing. His hierarchy posits physiological needs such as thirst, food, and rest as the base of a pyramid of motivation to satisfy physical needs, followed by safety needs, then love needs, then esteem needs, and finally self-actualization needs.

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  • O’Neill, Michael, Ann Pederson, Sophie Dupéré, and Irving Rootman. 2007. Health promotion in Canada: Critical Perspectives. 2d ed. Toronto: Canadian Scholars’ Press.

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    Canada provides a national case study in the rise and decline of health promotion as a rallying point for social and political perspectives on a “new public health.” Following Canada’s landmark Lalonde report and the International Ottawa Charter on Health Promotion, which became global touchstones, health promotion has struggled nationally. This book examines Canada’s national struggle and international influence. Also available in French: La promotion de la santé au Canada et au Québec: perspectives critiques (Quebec: Presses de l’Université Laval).

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  • Üstün B., and R. Jakob. 2005. Calling a spade a spade: meaningful definitions of health conditions. Bulletin of the World Health Organization 83:802.

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    This review of the debates on re-defining health casts a historical perspective on the still prevailing divine notions of health in the world religions and the struggle within health and social sciences to come to a more humanistic and adaptable definition that takes into account variations dependent on age, culture, and the balancing of personal and community responsibility.

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  • World Health Organization. 1948. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946 and entered into force on 7 April 1948. Geneva: World Health Organization.

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    The first lines of the Preamble declare, “in conformity with the Charter of the United Nations, that . . . [h]ealth is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This definition has become a lightning rod for academic and political debate over the past half century.

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  • Young, Lynne E., and Virginia Hayes. 2002. Transforming health promotion practice: Concepts, issues, and applications. Philadelphia: F. A. Davis.

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    Directed particularly at health promotion practiced in nursing, this book takes a postmodern approach to the broader need, in the authors’ and some of the contributors’ views, for an interdisciplinary approach to health that increases patients’ or clients’ control over their health and their lives.

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Reference Works

Reference sources for those grappling with definitional issues in public health are divided most notably between academic references and practitioner references. Most of the practitioner reference works include the textbooks described in the next section, whereas the academic reference works have tended to consist of specific articles that push the boundaries of the field. A few notable reference works that do cut across the academic or scientific and the policy and practice spheres are A Dictionary of Public Health (Last, et al. 2007), the Encyclopedia of Public Health (Breslow, et al. 2002), and the Encyclopedia of Health and Behavior (Anderson 2004). The most established and voluminous contemporary reference work in public health is the Oxford Textbook of Public Health, now in its fifth edition (Detels, et al. 2009).

  • Anderson, Norman B., ed. 2004. Encyclopedia of health and behavior. 2 vols. Thousand Oaks, CA: SAGE.

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    Behavioral science applications in health promotion and their theoretical underpinnings are described, from individual level interventions to prevent or manage diseases to policies and organizational issues. Each of the 200 titles is described in four to six pages by an expert in that subject.

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  • Breslow, Lester, ed. 2002. Encyclopedia of public health. 4 vols. New York: Macmillan Reference USA.

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    Descriptive summaries of the sciences, arts, practical skills, organization, essential functions, and historical traditions of public health. Among the over 900 entries in the four volumes, more than half relate to the social or behavioral aspects of public health. One article titled “Health” by John Last covers the prevailing definitions and distinguishes objective and subjective health.

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  • Detels, Roger, Robert Beaglehole, Mary Ann Lansang, and Martin Gulliford. 2009. Oxford textbook of public health. 5th ed. 3 vols. Oxford and New York: Oxford Univ. Press.

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    This classic textbook leaves the definitional issues to the 230 or so individual authors of chapters. Only one chapter deals significantly with the definition of health: Marcia Hills and Simon Carroll in chapter 7.3 (Vol. 2) trace the change of health concepts within the evolution of health promotion thinking in public health, and offers a table contrasting the approaches to health they have produced (see p. 755).

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  • Last, John, ed. 2007. A Dictionary of public health. New York: Oxford Univ. Press.

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    Definitions of some 5,000 words and terms used in public health science and practice. Definitions are cross-referenced with related terms. Website links are offered for further information on many terms. Health is given four definitions, two from World Health Organization (WHO) sources, one emphasizing a combination of physiological and functional ingredients, and one emphasizing a state of equilibrium or harmony between humans and their environments.

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Textbooks

Textbooks in public health generally offer a definition of health, or at least imply a definition of health within their definition of public health, as seen in Novick, et al. 2008 and Scutchfield and Kech 2003. Almost all quote, but most take issue with or debate, the World Health Organization’s (WHO’s) definition of health, such as in Gilmore and Campbell 2005, Koelen and van den Ban 2004, and Simons-Morton, et al. 1995. Some have shown the variety of alternatives available with new surveillance measures on populations as in Gilmore and Campbell 2005 and Simons-Morton, et al. 1995. Others, especially those in health promotion and behavioral aspects of health, have placed more emphasis than the WHO on social, subjective, and motivational dimensions of health, as seen in Bates and Winder 1984, Bedworth and Bedworth 1992, and Koelen and van den Ban 2004.

  • Bates, I., and Alvin Winder. 1984. Introduction to health education. Palo Alto, CA: Mayfield.

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    Defines health as “the capacity to cope with or adapt to disruptions among the organic, social, and personal components of the individual’s health system” (p. 36). This reference to “health system” departs from the usual organizational and service delivery usage, making it a term that places the individual in a broader system of organic, social and personal interactions whose equilibrium can be disrupted and will require health to compensate.

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  • Bedworth, A. E., and D. A. Bedworth. 1992. The profession and practice of health education. Dubuque, IA: William C. Brown.

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    Considers health a quality of one’s physical, psychological, and sociological functioning that enables one to cope with a variety of personal and social situations.

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  • Gilmore, Gary D., and M. Donald Campbell. 2005. Needs and capacity assessment strategies for health education and health promotion. 3d ed. Sudbury, MA: Jones and Bartlett.

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    Acknowledging the range of criticisms of the WHO definition, these authors offer suggested directions for new definitions implicit in the new surveillance and other measurement opportunities presented by diagnostic techniques and survey questions. The book is devoted to measures of population health needs and capacity.

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  • Koelen, Maria A., and Anne W. van den Ban. 2004. Health education and health promotion. Wageningen, The Netherlands: Wageningen Academic.

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    Devotes five pages to the question “What is health?” This text also uses Maslow’s hierarchy of needs to illustrate the levels of health and the order in which they need to be satisfied. Other chapters describe the evolution of health education and health promotion, WHO policy, and theories that have shaped these fields, and to health communications, community participation and intersectoral collaboration, designing programs, research, organization, management, and ethics.

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  • Novick, Lloyd F., Cynthia B. Morrow, and Glen P. Mays, eds. 2008. Public health administration: Principles for population-based management. 2d ed. Sudbury, MA: Jones and Bartlett.

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    Chapter 1 devotes three pages to defining public health as it relates to improving the health of populations. The activities of public health can be seen to define the health they are to improve. Similarly, a further discussion of the history of collective action to improve health traces the changing definition of health as reflected in what was seen as important action for public health.

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  • Scutchfield, F. Douglas, and C. William Keck. 2003. Principles of public health practice. 2d ed. Clifton Park, NY: Thompson/Delmar Learning.

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    In the chapter on “The Determinants of Health,” by John Last and J. Michael McGinnis, a section devoted to definitions of health mirrors the entries by Last in Last, et al. 2007 and in Breslow, et al. 2002 (both cited under Reference Works).

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  • Simons-Morton, Bruce G., Walter H. Greene, and Nell H. Gottlieb. 1995. Introduction to health education and health promotion. 2d ed. Prospects Heights, IL: Waveland.

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    Devotes eight pages to “Defining Health” (pp. 4–14) and another seven pages to “Measuring Health” (pp. 14–19). The former identifies three criteria for a dynamic understanding of health: subjective feelings, ability to function, and ability to adjust or adapt.

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Anthologies

Given the breadth of public health, and the numerous biomedical, social, behavioral, and administrative sciences that it draws upon for theory, research, and practice, books have turned occasionally to reprinting previously published articles and their multiple authors to represent areas of expertise within the field in which they have become specialized. This is true with respect to descriptions of the field in a particular country, as in Davies and Macdowall 2006 and O’Conner-Fleming and Parker 2001, and in particular disciplines, as seen in Sheinfeld Gorin and Arnold 2006.

  • Davies, Maggie, and Wendy Macdowall. 2006. Health promotion theory. Maidenhead, NY: Open Univ. Press.

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    Philosophical, methodological, theoretical, ethical and political underpinnings of health promotion to guide practitioners, particularly in the United Kingdom. Focus is on applying the ideas and concepts to practical program implementation. To illustrate best practices and provide evidence of what works, examples are drawn from several countries, representing different cultural backgrounds. Chapters contributed by other British authors.

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  • O’Conner-Fleming, Mary Louise, and Parker, Elizabeth. 2001. Health promotion: Principles and practice in the Australian context. 2d ed. Crows Nest, Australia: Allen & Unwin.

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    The authors, together with twelve other contributors to chapters, describe the social history of “the new public health” and the Australian national strategy for health promotion, then devote the remaining chapters to planning and evaluation skills and various settings for health promotion (schools, workplaces, Aboriginal communities, rural, etc.)

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  • Sheinfeld Gorin, Sherri, and Arnold, Joan. 2006. Health promotion in practice. San Francisco: Jossey-Bass.

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    Starting with a chapter titled “Images of Health,” the editors have organized a series of chapters following that on “Models of . . . ,” “Contexts for. . .” and “Agents for . . .” health and health promotion. These and subsequent chapters on specific aspects of health promotion, disease and injury prevention, collectively define the scope and variety of definitions of health.

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Journals

Public health, with its blending of disciplines and fields that had previously developed more independently, has inherited a convergence of journals having their origins in health behavioral research (e.g., American Journal of Health behavior), worksite wellness programs (American Journal of Health Promotion), international health (e.g., Global Health Promotion, Health Promotion International), and health education research and practice (e.g., Health Education Research, Theory and Practice, and Health Promotion Practice). The most generic and homegrown journals in public health are the American Journal of Public Health and the Annual Review of Public Health). All of these occasionally grapple with issue of the definition of health.

Criticisms of the WHO Definition and Specific Alternatives Offered

The interest in revisiting the World Health Organization (WHO) definition of health has gained recent momentum. Several articles have raised questions and criticisms about the most frequently quoted WHO definition as seen in Evans and Stoddard 1994, Jadad and O’Grady 2008, Last 2002, and Tarlov 1996. These and others have offered alternative definitions including those in Dubos 1968, Stokes, et al. 1982, and WHO Regional Office for Europe 1984.

  • Dubos, René. 1968. Man, medicine and environment. New York: Praeger.

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    Defines health as “enabling people to achieve a satisfying existence while coping with an imperfect world” (p.69). Dubos objected to the prevailing view that health and vigor can only be achieved through modern sanitation and western medicine. He believed that we can reach a high level of physical and mental health without nutritional abundance or physical support.

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  • Evans, Robert G., and Greg L. Stoddard. 1994. Producing health, consuming health care. In Why are some people healthy and others not? The determinants of health of populations. Edited by Robert G. Evans, Morris L. Barer, and Theodore R. Marmor, 27–64. New York: Aldine de Gruyter.

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    The criticism of the WHO definition in this chapter is that it makes health the objective for all human activity, leaving no room for a separate realm of uniquely health-oriented activity. The WHO definition makes all policy health policy.

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  • Jadad, A. R., and Laura O’Grady. 2008. How should health be defined? British Medical Journal. 337: 1361–1364.

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    After a literature search and conclusions about broad criticism of the WHO definition, Jadad calls for a global conversation on the web about the way “health” should be defined.

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  • Last, John M. 2002. Health. In Encyclopedia of public health. Edited by Lester Breslow, 519–526. New York: Macmillan Reference USA.

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    The WHO definition is critiqued here as describing a vague, theoretically ideal state seldom attained by real people. Last argues that it lacks ingredients readily measured or counted in either individuals or populations.

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  • Stokes, John, III, J. J. Noren, and S. Shindell. 1982. Definitions of terms and concepts applicable to clinical preventive medicine. Journal of Community Health 8:33–41.

    DOI: 10.1007/BF01324395Save Citation »Export Citation »E-mail Citation »

    As a committee product for an epidemiological association, this article defined some tangible elements of health such as anatomical, physiological, and psychological integrity. It also included abilities to perform family, work, and community roles, and to deal with various stresses; a subjective sense of well-being; and a “freedom from the risk of disease and untimely death.” All of these elements can be measured, although “the risk of . . .” in the last is not achievable.

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  • Tarlov, Alvin R. 1996. Social determinants of health: The sociobiological translation. In Towards a health policy for the 21st century. Edited by David Blane, Eric Brunner, and Richard G. Wilkinson. London: Routledge.

    DOI: 10.4324/9780203434932Save Citation »Export Citation »E-mail Citation »

    Tarlov reviewed alternative definitions over the preceding half century and found remarkable consistency in three elements that led him to this near-consensus definition: “Health is a capacity, relative to potential and aspirations, for living fully in the social environment.”

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  • World Health Organization Regional Office for Europe. 1984. Health promotion: A discussion document on the concept and principles. ICP/HSR 602. Copenhagen: WHO Regional Office for Europe.

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    Although never specifically challenging the preamble to the WHO Constitution, the European Regional Office of WHO proposed a working definition that was adopted at the 1986 International Conference on Health Promotion, which produced the Ottawa Charter. It emphasized that health is a resource for everyday life, not the objective of living.

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LAST MODIFIED: 02/23/2011

DOI: 10.1093/OBO/9780199756797-0132

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