Richard Smith: The end of disease and the beginning of health

Richard Smith I think I’m healthy, but am I right? I’m tubby. My hair is white and thin and gone altogether from some parts of my head. I’m short sighted and astigmatic. My Achilles tendon aches at times, and when I get out of bed in the morning I hobble. I haven’t had my blood pressure measured for a while; nor my blood lipids. My prostate is, I suspect, large, but I haven’t had it examined. Nor have I had my prostate specific antigen measured. And my bowel has not been sigmoidoscoped. My genes have not been examined, but I suspect something dreadful lurks there. My mother is dementing as her mother did before her. I often can’t remember names. I don’t smoke, but I drink more alcohol than the Royal College of Physicians thinks wise—and I’m rather too fond of pies. I walk a lot, cycle often, and run occasionally, but I don’t exercise as much as I should.

So as I complete this paragraph I’m convinced that I can’t be healthy: I’m a mass of imperfections, and I’ve not bothered to discover the hypertension or latent cancer that may be about to carry me off.

But what is health? For most doctors that’s an uninteresting question. Doctors are interested in disease, not health. Medical textbooks are a massive catalogue of diseases. There are thousands of ways for the body and mind to go wrong, which is why disease is so interesting. We’ve put huge energy into classifying disease, and even psychiatrists have identified over 4000 ways in which our minds may malfunction.

Health for doctors is a negative state—the absence of disease. In fact, health is an illusion. If you let doctors get to work with their genetic analysis, blood tests, and advanced imaging techniques then everybody will be found to be defective—”dis-eased.”

Could we, however, have reached a stage when the concept of disease has ceased to be helpful? It was useful in the 19th century as fever was broken down into a series of conditions with different prognoses and treatments. Mary Tinetti and Terri Fried have argued in the American Journal of Medicine that thinking in terms of disease has become counterproductive.. “The time has come,” they write, “to abandon disease as the focus of medical care. The changed spectrum of health, the complex interplay of biological and non-biological factors, the aging population, and the inter-individual variability in health priorities render medical care that is centred on the diagnosis and treatment of individual diseases at best out of date and at worst harmful. A primary focus on disease may inadvertently lead to undertreatment, overtreatment, or mistreatment.”

Consider a patient called Lucy. She has heart failure, diabetes, asthma, and osteoarthritis. Her cardiologist treats her heart failure, her diabetologist her diabetes, her chest physician her asthma, and her rheumatologist her osteoarthritis. Her general practitioner holds the ring and writes her prescriptions.

But actually she’s not much interested in her diseases, and she’s not worried about dying. Indeed, if she could get to see her son in Australia one more time she’d welcome death: life has never been the same since her husband died. She needs a travel agent, not five doctors, but doctors are supplied on the NHS and travel agents aren’t.

I’m coming close to flippancy, but in a world where most of medicine is concerned with people with multiple chronic conditions combined with social and family problems health care must be person not disease centred.

So I’m not happy with health being defined as the absence of disease. Nor am I keen on the World Health Organisation’s definition of “Complete physical, psychological, and social wellbeing,”a state reached only at the moment of mutual orgasm, joked Peter Skrabanek. It’s a ludicrous definition that would leave most of us unhealthy most of the time.

My favourite definition of the moment is Sigmund Freud’s definition, which was never written down by him, of “the capacity to love and work.” You might be hours from death and still healthy because you can love and work. Freud selected love and work because these are the things that he regarded as most precious—and many, including me, would agree with him.

But if you’re a traffic warden rather than the inventor of psychoanalysis you may
not be so keen on work. We are being led to the conclusion that we each must make our own definition of health—just as we each define “the good life.”

For you, it might be fast cars and fast women, whereas for me it’s being with my wife, drinking red wine, listening to Schubert, and writing blogs that probably nobody reads.

1. Tinetti ME, Fried T. The end of the disease era. Am J Med 2004; 116: 179-85.

This article is also being published in the Journal of the Science of Healing Outcomes. The author was not paid.

Competing interest: None.

  • Liz Wager

    At least one person read it … but maybe bloggers reading each other’s blogs is a new disease (but slightly less pathological than reading one’s own)

  • Thank you for this blog. As a teacher of preventive medicine I am concerned that we do too much to provide technical perfection. 40 years ago Ivan Illich said much the same as you in his ‘Limits to Medicine’ which is one of the first readings I require of my students. Part of the problem is that the media have trained their readers/viewers to expect instant cures for everything.

  • I read and enjoyed it. I find very reassuring being in good company as a non sigmoidoscoped and non prostate specific antigen measured fifty-year-old-man. You know, I have a definition of health of my own: you are really healthy and you can completely enjoy your life when you can forget the existence of doctors and hospitals. Someone can do it, but I can’t. As a doctor and a psychiatrist, and as a fifty-year-old-man, I know that I should screen my bowel and my prostate, etc., and I can’t really forget it. Probably, I should drink more red wine to reach Richard’s equilibrium…

  • Dr.Viveck Atheya

    Indeed, the concept of health and disease need a revisiting.The ‘disease’ has been analysed and broken down to such minute levels-body,cell,gene and molecule that it has confused us.We need to rethink about diseases at each level and then reintegrate it and workback to the macro level to redefine the definitions.
    It will be interesting to note that “Ayurveda” the Indian system of medicine has defined disease as “awareness of any part of body” as disease.We need commonsense to help us out.

    Viveck Atheya

  • dr ps

    This reminds me of what i read in text book of pathology by Robbins when I was an undergraduatemedical student…” if you look at the tree too much you miss the beauty of the forest”. Today the specilisation and superspecialisation of “Modern Medicine” is busy looking at the tree too much and has missed the beauty of the forest called – health..
    Dr P S Reddy

  • Robert Long

    I read your blog because I misread the title. I thought it was ‘the end of disease and the beginning of death’. Maybe because I work in aged care and I have such trouble drawing the line. Perhaps its not up to me to draw the line anyway- it worries me. And then we often seem to have folk who die an expected death with endstage cardiac disease or other organ failure and who have 10 or so medications on their chart on the day they die, including the usual mix of statins, ACE inhibitor, aspirin, biphosphonate, and sundry puffers and most fruitless of all the obligatory warfarin.

  • Paolo Magrassi MD

    Uno splendido, brillante,e così veritiero ” pezzo ” di Mr. Smith ! I would be so glad if he would write another ” piece ” on the anti-ageing craze ….

  • Excellent post, Richard. I’m with you in the 50-something untested so still feeling healthy group! I think this is SUCH an important issue. I frequently ask groups of health care professionals to give me a definition of health WITH NO reference to disease or illness. Pretty much they are stumped. Sometimes someone suggests something like Aristotle’s “eudaimonia” (often translated as “happiness” or the “good life” but better translated as “flourishing” – onto something there methinks!)
    The book I read which progressed my thinking about this was a collection of essays by the philosopher, Hans Georg Gadamer, “The Enigma of Health”. Interestingly, Dr Atheya, he says quite a lot about this concept of disease being awareness of part of the body.
    Personally I’ve found the newish concept of “complex adaptive systems” (“CAS”) to be helpful. A healthy CAS adapts ie it copes with change; it develops new behaviours and solutions to problems ie it is creative; and it is engaged ie it is in active interaction with its multiple environments.
    So that’s my definition – ACE – Adaptive/Creative/Engaged. That’s what I look for in patient outcomes. Someone who copes better, becomes more creative and more actively engaged with the world.

  • Les Simpson

    Richard Smith’s interesting commentary on his concepts of health and disease have drawn several significant responses. But none of those writers got to the real nitty gritty of good health which implies that because all tissues are functioning normally, then bodywide function is normal. Furthermore, normal tissue function implies that the rate of delivery of oxygen, metabolic needs, hormones, etc., are normal. Therefore if good health equates with normal tissue function, then normal rates of blood flow are needed for good health.

    But it is a strange feature of modern medicine that the very large literature which records changes in the flow properties of blood (blood rheology) in the major causes of morbidity and mortality is simply ignored. I have failed to locate a medical school which teaches blood rheology.

    Dr.Smiths reference to dementia can be used as an example. According to published reports based upon SPECT scans, the dementing process is accompanied by reductions in regional cerebral blood flow. I was greatly impressed by an early report of a man with myelomatosis. High levels of myeloma protein had greatly increased his blood viscosity. His major presenting symptom was dementia. When the myeloma protein was removed by plasmapheresis, normal blood viscosity was associated with normal brain function.

    I can only wonder if Dr.Smith is aware that his walking, running and cycling has the beneficial effect of lowering his blood viscosity. Although low level physical activity has ben shown to improve the quality of life in patients with major depression, post-natal depression and multiple sclerosis for example, such studies usually make no comment on the mode of action of the beneficial effects of exercise.

    In a 1998 review, Ajmani and Rifkind from NIH reported that the aging process was accompanied by an increase in blood viscosity and a reduction in red cell deformability. Such changes will have a detrimental effect on blood flow which will contribute to the functional changes which accompany aging. Because such changes are potentially treatable, it is difficult to imagine what savings in healthcare might result from the treatment of the blood rheology changes of the elderly. Such treatment would sustain the feeling of good health and their quality of life and their independence. But in the absence of treatment,the changes in blood rheology will contribute to tissue dysfunction in various parts of the body which would be conceived as ill health.

    The patient Lucy, may provide a good example of a situation where blood rheology problems have not been recognised. In 1966, Lancet published the first report of increased blood viscosity in type 1 diabetes. Many other reports have confirmed that finding, but there seems to be no clinical recognition of that information. Similarly, there have been many reports of changed blood rheology (frequently these are cholesterol related) in cardiovascular disease. But the failure to recognise such information meant that Lucy saw both a diabetologist and a cardiologist.

    In a world,”…where most of medicine is concerned with multiple chronic conditions combined with social and health problems,” it is essential to recognise that stress of any kind will amplify the changes in blood rheology and worsen tissue dysfunction and symptom severity. For example, the effects of cancer on the internal environment alter blood rheology and red cell stiffness. The post-radio and chemo-therapy worsening of symptoms are accompanied by an amplification of the blood rheology changes. Such changes reduce in concert with symptom severity. Similar observations could be made about other chronic disorders.

    Until it is recognised that normal rates of blood flow are an essential component of good health, it is unlikely that treatments aimed at normalising blood flow will be used to increase the quality of life of those who live in chronic ill-health.

  • Matt James

    Dear Richard,

    I have recently turned 40 … the same day you turned 56. Thoughts sometimes turn to my impending need for invasive checks that we are told to consider beyond this age. It’s refreshing to consider new approaches such as health vs disease, but how would it benefit in practice? Or indeed benefit a practice?

    Maybe there is some middle ground we can aim to achieve, between accepting both? We once did the London to Brighton together which is great as a one off now and again, but I think that my hilly 1.6 mile ride to the BR station lock up each day is the steady healthy supping of exercise as opposed to the binge of a 60 mile ride once a year, or the addict’s 4 sessions a week at the gym doing a spin class.

    Most things in excess are bad for you. We are designed to do what is required to keep us alive, not sit and eat saturated fats in front of the TV all day nor go for a 5 mile run before work each day. Obese people suffer from more from disease and die young, highly tuned athletes regularly explode in a heap of ruptured muscle, stress fractured bone and shredded tendon. Just look at our decimated Olympic squad!

    Then there is mental health, possibly our most neglected area of wellbeing. We should find things which amuse us as we get older, I think people laugh less with age and the relentless pressures that life dishes up dampen our moods too often. We all need to have time, again in moderation, to press the reset button and see life for what it is, reflect, take time out with people of our choice then pick up and start again.

    I guess, in conclusion, I believe a long healthy life is all about moderation, or if you are very lucky, the super-gene. Even this post will be moderated?!

  • Tracey Lynn Perez Koehlmoos

    Excellent posting Richard. Freud v. the WHO definition of health…I think there is a strong relationship between the two. If you consider that the social determinants of health without mentioning them specifically, include concepts from Freud that support Love and Work, which almost universally play a strong role in well-being and self-concept if not necessarily “health.”

    And, yes, we should all exercise more, eat less and make love more often!

  • Gary Rimmer

    What quaint 20th century ideas you still have Richard. Health and Disease? Surely nowadays we all just have ‘lifestyles’ with differing ranks of clinical facilitators.

  • shaun

    It really nice to read that “Ayurveda” the historical Indian system of medicine explain diseases as “awareness of any part of body” as disease.
    Addiction Recovery South Dakota

  • Peter Ward

    When seeing patients with multiple prediseases, things that threaten harm but don’t make you feel ill (NIDDM, BP, stable angina, high chol. etc), I have wondered what replies I would get if I could ask the patient ” Now what would you rather have; simvastatin, aspirin, amlodipine, losartan and regular blood tests, or £40 a week cash and a free bus pass. I wonder which would improve health more?

  • Dr.N.P.Viswanathan

    Age is not a criteria. Feel young, be happy.Age grace fully.

  • the capacity to love and work – really great.
    OR other one similar which I like:
    “Health is a condition of highest freedom of an individual”.

  • Lorenzo Chiti

    Health seems more connected to the spiritual life than with the physical body.
    The way I live matters much more than the level of natural decay my body has reached today. Has anybody ever not died or not got sick? Should we frustrate ourselves in the futile project of never getting sick? The definition of health is a very very important issue. As doctors we constantly aim to reduce symptoms, or ameliorate function, noble purposes but we have to remember that it is a lost battle: to be alive is a definitive death sentence…

  • Gealanruby

    That is a very informative blog. As a health care practitioner, Health is wealth , it plays how a person will enjoy the freedom to live in the community. Healthy person will enjoy life but we cannot prevent that our body will deteriorate as aging occurs,it is inevitable part of life… “die as healthy”???? correct me if i'am wrong… As the immune system and our body is deteriorating the chances of being “SICK” is unavoidable, but thru the sophisticated and innovative inventions in technology, Doctors are easily now to discuss to their client what are preventive measures to avoid to get sick if not how to reduce symptoms and be treated. “LOVE you self and your environment” perhaps will help us to stay young and healthy…. not only our work but the environment we live in.

  • Gene Balliett

    I just read this blog of yours, Richard Smith, and I liked it a lot. Also, I like your way of living the good life. Keep on keeping’ on. 
    Gene Balliett

  • Sarah Chiejina