Positive health and health promotion: Two ideas that shift my thoughts on health work

Positive health
A major idea that has reoriented my thoughts about health work has been my growing appreciation and understanding of "positive health". In our typical, biomedicine-based use of the term health is defined negatively as the "absence of disease". To be healthy means to not have an illness and to be sick means to have an illness. It's a binary, you are either one or the other, health or sick. We therefore think of working for good health as found in either disease prevention or disease treatment.

The World Health Organization, however, gives health a positive definition and sees it as "full social, mental, and physical well-being". While the extreme position of "full" well-being in those aspects is impossible - we all at any time have some issue or another - it does create a spectrum of health, ranging presumably from death to "full" well-being.
The advantages to this positively defined vision of health are many. The first and probably most important is that one can more easily understand health work that does not revolve around disease treatment or prevention but instead increases the social, physical or mental well-being of a person or population. Some examples for each include:
o Physical well-being: A farmer increasing crop yields in a malnourished population through watershed development.
o Social well-being: Local businesses' improve local economies and prevent migrant work.
o Mental well-being: Communities address chronic alcohol habits and domestic abuse.
I would define such work as "health promotion". Instead of disease treatment or disease prevention - the classical realms of medicine and public health - health promotion works on increasing a person or population's well-being and shifts them to the right on the scale.

Such a reconceptualization of health and health work is important for creating better health for people in the developing world. It has been stated many times that the major reason for the health advances in the West are not due to increases in medicines or treatments but instead in medical knowledge about hygiene and a general increase in the standard of living. These advances had the effect of creating a healthier environment for us: sanitation, clean water, adequate nutrition, decent living spaces, protection from insects, etc. The evidence for this argument largely draws from the observation that increased life expectancy and decreased disease levels in the West largely preceded medical advancements.

Yet when we think about health work or health ministries in the developing world most people tend to stay focused on a doctor-centered, disease-treatment approach. I think that seeing health through a positive definition of well-being rather than the negative of disease-absence allows one to see more clearly the importance of sanitation, clean water, adequate nutrition/crops, better social relations, less "isms" (racism, casteism), greater gender equality, and increased incomes. They aren't "peripheral" or "distal" factors related to health because you don't have to make the longer, conceptually more difficult connection of these to disease prevention. Instead, one can easily see how they relate directly to health promotion and better well-being and health.

Related Thoughts:
Paul Farmer:

One interesting debate I have been having while here is how Paul Farmer's work interacts with Primary Health Care (PHC) and health promotion. I feel that Farmer and PHC share a common analysis of disease etiology: it is more related to social factors and structural violence than biological factors. I think they both see illness as a result of poverty, gender inequality, racism, and other factors rather than merely an unfortunate biological event. Yet they differ in what they do in response.

Paul Farmer makes a very powerful argument for making sure that people have access to medical care. He does, certainly, write constantly about lack of housing and adequate nutrition as important factors in disease creation but he doesn't seem to advocate wholesale programs for development but rather housing and food as a part of disease treatment. He is the one who writes on the prescription pad next to the medicines, "housing" and "money" as necessities for this patient's health but I don't see systematic efforts to work on these factors in a population. Instead, he seems to stay focused on ensuring that populations have access to quality and efficacious medical care, most famously DOTS for TB and anti-retrovirals for AIDS.

I didn't think I would ever say this but I kind of wonder if I prefer PHC to Farmer's technique. To be fair, he seems to be responding to epidemics in many places (Lima, Siberia, Rwanda) but he does also set up general health centers in Haiti and Rwanda. I would like to know more about what happens at these before I say anything with certainty as I have never been there, but he hasn't written about general development work (sanitation, clean water, housing, watershed development) to my knowledge.

Advantages to health as a spectrum, not a binary

One other important implication created by switching health from "the absence of disease" and a binary to "full social, mental, and physical well-being" and a spectrum is found in how you can work with the spectrum. I find it more conceptually satisfactory when it comes to some situations that become hazy in the diseased/no disease binary. For example, someone with depression may have a couple of hard days in a row or a depression episode but feel well for days or even weeks at a time. When they are feeling fine are they still "depressed"? Are they still "ill"? What does it mean to be "ill" but not feel it for days or even weeks at a time? They aren't easily said to be either sick or not sick but instead somewhere in between. In these cases, I think it makes more sense to put the person on a spectrum, wherein depression episodes may shift them left but the more they heal the more they shift to the right.

One issue that arises is how the spectrum works. Placing illnesses on the spectrum as if cancer puts you here and diabetes there doesn't work because it stays within a disease-centric model of health. Where do important health and disease producing factors such as exercise, smoking, obesity, family, bullying, etc. fall on the list? Furthermore, such an attempt would miss all of the other factors (economic, social, and mental) that will be influencing how that person experiences that illness: will she have the money for treatment? will she be ostracized and kicked out of the family? does she have the social support and mental capacity to withstand it?
Instead, I think it's more useful to see that health and disease producing factors shift people either to the right or the left.
In this way one can take into account all of the factors working to create health and disease. One can take into account how war or bullying shift one to the left or how exercise, secure employment, and good social relations can shift one to the right. It works well for understanding how social, economic, and political realities as well as personal decisions impact health.
One intriguing activity is to attempt to figure out the magnitude of the shift for each factor in affecting health and well-being. It would be a difficult activity but I think it could be conducted similarly to how the Disability Adjusted Life Years (DALYs) were done and also used to determine where health resources should be done.

For those unfamiliar with DALYs, the WHO and top universities collaborated in a series of conferences to determine the relative impact of certain illnesses or infirmities - malaria, AIDS, flu, blindness, paralysis - on a person's health through questions basically saying which would make you worse off, and then took these relative numbers as multipliers and applied them to prevalence to come up with worldwide disease burden, as per my understanding. In effect, they attempted to calculate which illnesses are causing the most trouble today and therefore deserve the most funding and attention.

I think a similar process for health- and disease-producing factors would be absolutely fascinating as well as important. Instead of being once again disease-centered like DALYs, this analysis would focus on the relative importance of war, gender inequality, exercise, diet, bullying, poverty, clean water, nutrition supplements, micro-credit schemes, spirituality, community cohesion, etc. After such an analysis one would have a good sense of the most important in general health- and disease-producing factors and could focus funding and attention on these.
It would be a tall order, but it would certainly be important and useful.