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.