BMJ BM2011;343d4163doi:10.1136bmjd4163 Page 1 of 3 ANALYSIS How should we define health? The WHo definition of health as complete wellbeing is no longer fit for purpose given the rise of chronic disease. Machteld Huber and colleagues propose changing the emphasis towards the ability to adapt and self manage in the face of social, physical, and emotional challenges Machteld Huber senior researcher, J Andre Knottnerus president, Scientific Council for Government Policy Lawrence Green editor in chief, Oxford Bibliographies Online-public health, Henriette van der Horst head, Alejandro R Jadad professor Daan Kromhout vice president, Health Counci of the Netherlands, Brian Leonard professor, Kate Lorig professor, Maria Isabel Loureiro coordinator for health promotion and protection,, Jos W M van der Meer professor, Paul Schnabel director 11, Richard Smith director 12, Chris van Weel head 13 Henk Smid director 14 ouis Bolk Institute, Department of Healthcare and Nutrition, Hoofdstraat 24, NL- 3972 LA Driebergen, Netherlands; Department of General Practice, Maastricht University, Scientific Council for Government Policy, Postbus 20004, NL-2500 EA The Hague, Netherlands: Department of Epidemiology and Biostatistics, School of Medicine, University of California at San Francisco, USA; " Department of General Practice, VU Medical Center Amsterdam, Netherlands; Centre for Global eHealth Innovation, Toronto General Hospital, Toronto, Canada: Department of Public Health Research Wageningen University, The Hague, Netherlands; 'Pharmacology Department, National University of Ireland, Galway, Ireland; Stanford Patient Education Research Center, Palo Alto, CA, USA; National School of Public Health/New University of Lisbon, Portugal; General Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands: Netherlands Institute for Social Research, The Hague, Netherlands: t2UnitedHealth Chronic Disease Initiative, London, UK; Department of Primary and Community Care, Radboud University Nijmegen Medical Centre; Netherlands Organisation for Health Research and Development, The Hague, Netherlands The current Who definition of health. formulated in 1948 system. New screening technologies detect abnormalities at describes health as"a state of complete physical, mental and levels that might never cause illness and pharmaceutical social well-being and not merely the absence of disease or companies produce drugs for"conditions "not previously nfirmity. At that time this formulation was groundbreaking defined as health problems. Thresholds for intervention tend to because of its breadth and ambition. It overcame the negative be lowered--for example, with blood pressure, lipids, and sugar. definition of health as absence of disease and included the The persistent emphasis on complete physical wellbeing could physical, mental, and social domains. Although the definition lead to large groups of people becoming eligible for screening has been criticised over the past 60 years, it has never been or for expensive interventions even when only one person might adapted Criticism is now intensifying, and as populations age benefit, and it might result in higher levels of medical and the patter ilLnesses changes the defini dependency and risk. ounterproductive.The paper summarises the limitations of the The second problem is that since 1948 the demography of /HO definition and describes the proposals for making it more opulations and the nature of disease have changed considerably. useful that were developed at a conference of intemational health In 1948 acute diseases presented the main burden of illness and experts held in the Netherlands. chronic diseases led to early death. In that context WHO Limitations of who definition articulated a helpful ambition. Disease patterns have changed, with public health measures such as improved nutrition, hygiene Most criticism of the WHO definition concerns the absoluteness and sanitation and more powe althcare interventions The of the word"complete"in relation to wellbeing. The first number of people living with chronic diseases for decades is medicalisation of society. The requirement for complete health pattern is increasingly burdened by chronic disease."ortality increasing worldwide. even in the slums of India the "would leave most of us unhealthy most of the time. It therefore supports the tendencies of the medical technology an Ageing with chronic illnesses has become the norm, and chronic drug industries, in association with professional organisations, diseases account for most of the expenditures of the healthcare to redefine diseases, expanding the scope of the healthcare system, putting pressure on its sustainability. In this context the Correspondence to M Huber m huber@louisbolk nl REprints:http://journals.bmjcom/cgi/reprintform Subscribehttp:/resources.bmjcom/bmj/subscribers/how-to-subscribeHow should we define health? The WHO definition of health as complete wellbeing is no longer fit for purpose given the rise of chronic disease. Machteld Huber and colleagues propose changing the emphasis towards the ability to adapt and self manage in the face of social, physical, and emotional challenges Machteld Huber senior researcher 1 , J André Knottnerus president, Scientific Council for Government Policy 2 , Lawrence Green editor in chief, Oxford Bibliographies Online—public health 3 , Henriëtte van der Horst head 4 , Alejandro R Jadad professor 5 , Daan Kromhout vice president, Health Council of the Netherlands 6 , Brian Leonard professor 7 , Kate Lorig professor 8 , Maria Isabel Loureiro coordinator for health promotion and protection9 , Jos W M van der Meer professor 10 , Paul Schnabel director 11 , Richard Smith director 12 , Chris van Weel head 13 , Henk Smid director 14 1 Louis Bolk Institute, Department of Healthcare and Nutrition, Hoofdstraat 24, NL-3972 LA Driebergen, Netherlands; 2Department of General Practice, Maastricht University, Scientific Council for Government Policy, Postbus 20004, NL-2500 EA The Hague, Netherlands; 3Department of Epidemiology and Biostatistics, School of Medicine, University of California at San Francisco, USA; 4Department of General Practice, VU Medical Center, Amsterdam, Netherlands; 5Centre for Global eHealth Innovation, Toronto General Hospital, Toronto, Canada; 6Department of Public Health Research, Wageningen University, The Hague, Netherlands; 7Pharmacology Department, National University of Ireland, Galway, Ireland; 8Stanford Patient Education Research Center, Palo Alto, CA, USA; 9National School of Public Health/New University of Lisbon, Portugal; 10General Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands; 11Netherlands Institute for Social Research, The Hague, Netherlands; 12UnitedHealth Chronic Disease Initiative, London, UK; 13Department of Primary and Community Care, Radboud University Nijmegen Medical Centre; 14Netherlands Organisation for Health Research and Development, The Hague, Netherlands The current WHO definition of health, formulated in 1948, describes health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”1 At that time this formulation was groundbreaking because of its breadth and ambition. It overcame the negative definition of health as absence of disease and included the physical, mental, and social domains. Although the definition has been criticised over the past 60 years, it has never been adapted. Criticism is now intensifying,2-5 and as populations age and the pattern of illnesses changes the definition may even be counterproductive. The papersummarisesthe limitations of the WHO definition and describesthe proposalsfor making it more useful that were developed at a conference of international health experts held in the Netherlands.6 Limitations of WHO definition Most criticism of the WHO definition concernsthe absoluteness of the word “complete” in relation to wellbeing. The first problem is that it unintentionally contributes to the medicalisation of society. The requirement for complete health “would leave most of us unhealthy most of the time.”4 It therefore supportsthe tendencies of the medical technology and drug industries, in association with professional organisations, to redefine diseases, expanding the scope of the healthcare system. New screening technologies detect abnormalities at levels that might never cause illness and pharmaceutical companies produce drugs for “conditions” not previously defined as health problems. Thresholds for intervention tend to be lowered—for example, with blood pressure, lipids, and sugar. The persistent emphasis on complete physical wellbeing could lead to large groups of people becoming eligible for screening or for expensive interventions even when only one person might benefit, and it might result in higher levels of medical dependency and risk. The second problem is that since 1948 the demography of populations and the nature of disease have changed considerably. In 1948 acute diseases presented the main burden of illness and chronic diseases led to early death. In that context WHO articulated a helpful ambition. Disease patterns have changed, with public health measuressuch asimproved nutrition, hygiene, and sanitation and more powerful healthcare interventions. The number of people living with chronic diseases for decades is increasing worldwide; even in the slums of India the mortality pattern is increasingly burdened by chronic diseases.7 Ageing with chronic illnesses has become the norm, and chronic diseases account for most of the expenditures of the healthcare system, putting pressure on its sustainability. In this context the Correspondence to: M Huber m.huber@louisbolk.nl Reprints: http://journals.bmj.com/cgi/reprintform Subscribe: http://resources.bmj.com/bmj/subscribers/how-to-subscribe BMJ 2011;343:d4163 doi: 10.1136/bmj.d4163 Page 1 of 3 Analysis ANALYSIS