An award-competing entry

This is another item from the vault, something I wrote in the attempt to win an essay contest that the Global Forum for Health Research was running around the middle of 2006. The theme was 'combating disease and promoting health'. Sadly, I didn't win. In retrospect it's a bit clunky, and could perhaps have been dressed up a bit better. Still, it's a decent read and I stand by the points I made. I like to think if I'd said I was from a developing country I'd have won pants down. Perhaps this all served me right for prostituting my goddess-given writing ability in the pursuit of glory and gold.

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Rethinking Health Promotion

In the debate on how to promote health, I can think of no better starting point than to define what it is we actually mean by health. According to the Collins Concise Dictionary, health is:

“The state of being bodily and mentally vigorous and free from disease”

I would like to use this definition as the basis for a discussion of what it would really mean to promote the health of all people around the world today.

The first part of this definition is noncontroversial, obvious even. Good health means good physical health — the absence of bumps and bruises, aches and pains, stresses and strains. The second component, mental vitality, is far too often neglected. Indeed it appears that little more than lip service is paid to the notion of promoting mental health. The final term in our dictionary definition of health, freedom from disease, is also not as clear-cut as it may seem, as will be discussed further below.

As a society we do far too little to promote mental health. How can I justify this serious claim? For starters, how can you promote mental health when there is no consensus on what it is! Is it happiness? Peace of mind? A state of grace? Or is it merely the absence of illness? We seem to be quite good at defining mental illness. Not only do we think we know what it is, we keep adding to the list. There are a myriad medical manuals devoted to documenting and reifying all sorts of mental maladies. Incidentally, there are clear conflicts of interests in the writing of these manuals. Sheldon Krimsky, of Tufts University, has found that contributors to the widely used Diagnostic & Statistical Manual IV often have financial ties with companies selling treatments for these disorders. Where are the manuals for mental health?

To be fair, mental health is not much different from physical health in this respect. The majority of medical science proceeds by focusing on illness, rather than health. Over the years this has been a remarkably fruitful strategy, and it still has its place. Yet any researcher will tell you we are still a long way from a complete understanding of even ‘simple’ organisms. As controversial scientist Craig Venter eloquently put it, “We don’t know shit”. In the mental sphere we are even more in the dark (despite regular sensational reports to the contrary in the science media). If we want to take health to another level, both physically and mentally, sooner or later we must shift our focus from illness to wellbeing.

Of course, it is a luxury to ponder questions that must seem terribly remote to those in the midst of acute physical and mental trauma. Shouldn’t we be tackling these problems first? Sadly, our record of public and private support for mental illness is woeful. It is in areas of treatment and community support, rather than research, that we really let ourselves – and I do mean ourselves - down. While the main sufferers of mental illness are the afflicted themselves, society also bears the burden of mental illness gone undetected, untreated and effectively punished. Amongst the homeless, the incarcerated and the lower rungs of society the mentally sick are overrepresented. This last point may be no coincidence. Michael Marmot, of University College London, has found evidence to suggest a relationship between inequality and poor physical and mental health.

Yet along with the luxury to think about these things comes the responsibility to think big. Returning to the question of mental health promotion, what we need are some indicators of mental health. What about happiness? For all the material advances of certain countries, there is no evidence that people living in these countries are any happier than they were in the past. Not only this, but are they any happier than people living in different countries? This is no excuse for maintaining the disgraceful discrepancies between the haves and have nots, both within and between countries. It simply demonstrates that, above a certain baseline, there is no clear link between income and happiness.

And happiness is but one measure of mental health. What about a sense of belonging, the opportunity to fulfil one’s potential (in other words self-actualisation), a connection with the natural environment, mental stimulation, a feeling of control over one’s life? I suspect that the reader could contribute many items to a checklist of mental health indicators. You get an idea of how neglected this area is by the amount of questions it raises. What sorts of employers create a workplace that promotes mental health? What sorts of communities contain mentally healthy people? What sorts of environments are good for your mental health?

Moving away from the mental realm, we are closer to knowing the kinds of things that promote physical health. Diet is obviously important. So is some sort of regular exercise, although I suspect it would be more beneficial if it were integrated into our lives rather than slotted in twice a week between morning and afternoon meetings. Don’t be surprised if you are soon told which genes you need to be healthy, thanks to the massive investments being made into identifying genetic markers of disease. One problem with focusing on the genetic basis of disease, as David Suzuki has pointed out, is that it can shift the burden of responsibility onto the individual, rather than the firms which create hazardous work environments or emit pollutants, and the governments which regulate them. We would benefit by diverting some of our resources towards understanding these controllable environmental factors.

The last part of the dictionary definition of health is freedom from disease. While we are diverting resources, we would do well to remember that millions of people suffer from entirely preventable illnesses. We could make a huge dent in these very quickly by dramatically increasing funding targeted to those most at risk. Rather than detailing grim statistics on life expectancy, infant mortality and malnourishment, I would make two points, both of which apply locally and globally. Firstly, we must judge ourselves by how we treat those who are least well off. Secondly, acting is not a matter of charity, but obligation.

Can we all eventually be free from disease? This sounds like a reasonable request at first blush. Indeed it is the implicit underpinning of medical science. But on closer inspection, disease is a blurry concept (as are most useful concepts, by the way). There is a continuum from the obvious (eg HIV) to the mostly obvious (cancer is a disease, but it shares its lifeblood – mutation – with evolution), to the conditional (sickle cell anaemia arises from the trade-off between healthy blood cells and malaria resistance), to the ambiguous (eg a slightly less effective version of some metabolic enzyme). As with mental illness, it is in the interests of some to have the broadest possible definition of disease. If we take this to its logical conclusion, we reach what I call Clarke’s Principle: there is a disease phenotype for every genotype. In other words, if you look hard enough, you’ll find in every single person some inherited deficiency with respect to the majority of the population.

In this technical sense, none of us are or ever will be free from disease. It is a statistical impossibility, unless we all become clones of one another. In the case of more clear-cut diseases, can we realistically evade them completely? In nature the battle against illness and disease is perpetually waged but never won. Gains in one generation are lost in the next. The vanquishing of one illness merely paves the way for another. We cannot use this as an excuse not to act in the face of people dying preventable deaths. But even this is not so straightforward. How far do we go to prevent a centenarian from dying? Researchers are now openly discussing the possibility that we may never die. Is this the sort of health we want to promote? How will this affect the environment? Our children? I suspect that before we reach immortality something will cut us down a notch, not because I am a doomsayer but because I see no reason to exempt us from the sort of cyclical fluctuations of boom and bust that beset other species.

In conclusion, if we are serious about health promotion there are several things we can do as individuals and as a society. We must address inequality in access to healthcare. We must take mental illness seriously. But it is not enough to fire disease; we must promote health. As a corollary, we must define health in terms of more than just the absence of illness. Lastly, we should not confuse standard of living with quality of life. One has been rising in some countries for decades, but it appears to have completely detached from the other. Few would argue that good health is a prerequisite to a reasonable quality of life. Let’s make our society reflect this.