DEBATE DEBATE

Public health and individual morbidity

It may be pertinent to speak of a health-disease dyad, but such pairing has its price. A dyad is more than just two of a kind; it implies a certain categorical opposition where one term excludes the other - either healthy or not healthy. The opposite of health is non-health (or "unhealth"), which may be disease, illness, sickness, or malady, so there is no real dyad unless we create one: health-morbidity. Whereas disease, illness, and sickness form a family of concepts in need of definitions, the German Krankhei or its Spanish equivalent enfermedad are polysemous and open to hermeneutic interpretations. The differences are cultural, and translations only stress and distort the actual use of language. Too much emphasis is put on [arbitrary] definitions; what matters are the actions that such concepts denote and elicit.

There seems to be fair agreement that disease is a medical description of organismic disorders, subject to hard description and quantification aimed at achieving causal explanations and specific interventions, whereas illness is the experience of abnormality in form or function. Disorder and deviation necessarily refer to some standard of normalcy which may be described for the species (Boorse), although it seems more to the point that the individual constitutes his own standard of health/morbidity (K. Goldstein). Nevertheless, it is rarely acknowledged that feeling ill may lead to two different attitudes: unexplained, intolerable, and uncontrollable suffering that leads one to seek therapeutic assistance; or physical discomfort that is predictably temporary and expected to go away spontaneously. The difference is between suffering hematuria and having the flu, between having an illness and feeling sick. This important distinction needs a name and in fact has one in daily parlance: a person feels sick after eating spoiled seafood, or suffers from sea-sickness, or a pregnant woman feels morning sickness but knows she is not ill. All such cases of sickness will probably not lead the individual to seek medical advice. While illness leads one to seek medical help, sickness remains in the realm of bearable unpleasantness.

The habitual experience of sickness disowns Twaddle's suggestion that it is a social label assigned to individuals incapable of performing their roles in a normal way. If philosophy is not to interfere with the actual use of language (Wittgenstein), then sickness is a term that must preserve its everyday use, thus denying that society participates in defining morbidity. Rather, social forces analyze medical labeling of disease and decide upon pertinent strategies for insurance, medical care, subsidiary financing, and resource allocation. Medicine describes organismic disorders, while society evaluates them. In order to adequately fulfill their functions, public policies must find a fit between the scientific view of disease and the subjective experience of uncontrollable illness.

It is true that illness, medical definition of disease, therapeutic efforts, and social support are all culturally influenced, and social environments certainly play a central pathogenic role in many disorders. Nevertheless, it is the individual who experiences illness, and it is in the unique physician-patient encounter where disease is detected, labeled, and subject to appropriate treatment. All these experiences are of course value-laden, and it is a mistake to aim at value-free definitions in the health/morbidity complex. Bioethics has stressed that medical excellence depends on taking due notice of the subjective illness component. The clinical encounter, where illness is presented and disease is recognized, is a strictly medical situation, although strongly influenced by many extra-medical factors.

Where does this perhaps excessively detailed analysis leave the concept of health? Is it not, after all, the default state of any organism which has no [detectable] morbidity - Bichat's silence of the organs? Health is not an experience, nor is it a recognizable state of the organism, for medicine can probe and certify the normalcy of certain functions, but never exhaustively of the organism as a whole. Medical efforts aim at eliminating disease, or preventing it when a person is vulnerable: its task ends when disease is removed (Gadamer). If health could be described and medicine were to be charged with protecting it, we would be opening the doors to an incommensurable and undesirable medicalization of human life, far beyond what already occurs. All the more so if we give in to the temptation of creating total health-disease objects with hierarchical levels, for then health and disease become an endless laboratory exploration in the sub-individual realm.

If health remains a negative idea, it ceases to sustain health care programs and public health policies, which appear to become conceptually void and fall into pragmatic sterility. Does this also make public health a non-entity? Certainly not. Morbidity in all its forms is a state of individual organisms. Public health cannot be a state, it rather must be seen as an environmental process concerned with creating social and ecological conditions of such quality as to help citizens avert morbidity and become less vulnerable to external noxae. More than a positive concept of individual health, we need to act upon socially induced pathogenic factors and create living conditions that allow single organisms to live in biologically and anthropologically friendly environments, free from the risks of social and ecological toxicity. We might gain some distinctness and clarity of concepts if we spoke of public health as a social strategy to reduce the risks of individual morbidity - disease, illness, and sickness according to agreed-upon definitions. Public health acts at the collective level to control factors that cause disease and influence the organism's well-being from outside the individual, whereas medicine is less concerned with health than with treating derangements that occur within the individual. If more efficient public health policies lead to less individual morbidity, we will have thereby discovered a true and useful dyadic relationship.