Chapter 1 Concepts of Health and Illness

Concepts of Health and Illness

After completing this chapter, the reader will be able to:

These topics address the Medical Council exam objectives, section 78-1, and 78-9 for the Indigenous health component.

Note: The colored boxes contain optional additional information; click on the box open it and to close it again.
Words in CAPITALS are defined in the Glossary

Chest pain – disease or symptom?

Paul Richards consults Dr. Rao about his state of health. Paul hasn’t really been well since he lost his job five years ago. He is now complaining of tiredness and chest pain, which Dr. Rao thinks is probably angina. Dr. Rao is reflecting on the case. He will certainly investigate the chest pain, but he believes that Paul’s job loss is the underlying cause of his ill-health and that the best therapy for Paul would be another job. However, Dr. Rao can’t just prescribe one. He could refer Paul for social or psychological counselling, but is not sure if that would be of any use. He would like to see Paul at least take up a hobby or voluntary work, which might take his mind off his symptoms and renew his interest in life.

Introduction: the Widening Scope of Medicine

Over the past half-century, the Canadian population has seen unprecedented gains in longevity, health, and well-being. Improvements in the environment and in health policies, changing lifestyles and therapeutic advances have all contributed to enhancing the length and quality of life.

We can now expect to live into our 80s.

Improving Health in Canada

Mortality rates have been declining for many years. When adjustments are made (see Chapter 5, “Confounding”) to remove the effect of the rising average age of the population, Canadian mortality from all causes fell from 8.8 deaths per thousand population in 1950 to 7.0 in 1985, but then rose to an estimated 7.9 by 2023. Projections suggest an increase to 10.5 by 2050. The average age at death, however, is rising and premature mortality (deaths before age 75) fell from 5.4 years of potential life lost per thousand in 1981 to 2.8 in 2013.

There has been a corresponding rise in life expectancy, the number of years a newborn Canadian can expect to live. Life expectancy at birth increased from approximately 71 years in 1961 to almost 79 years in 1996, and reached 82 years in 2019. (Statistics Canada)

Because newborns depend entirely on a supportive environment, the health of infants offers a useful indicator of family circumstances, of the quality of health services, and of economic conditions in general. The Canadian infant mortality rate has been declining for 50 years. In 1982 there were 9.1 infant deaths for every thousand live births. This fell to 5.6 deaths in 1996 and 4.4 in 2021. Although commendable, this places us well below other industrial nations, such as France at 2.7 or Japan, which had the lowest IMR at 1.6 deaths per 1,000 live births in 2022.

Other health trends include the following:

The Canadian Cancer Society summarizes cancer trends. Cancer forms the leading cause of death in Canada, although survival rates have improved markedly. Around 43% of Canadians will be diagnosed with a cancer in their lifetime, and 1 in 4 will die from cancer, causing around 81,000 deaths in 2022. Although it has declined steadily, lung cancer remains the form most commonly diagnosed (an estimated 30,000 new cases and 20,700 deaths in 2022), followed by breast cancer (28,900 new cases and 5,500 deaths) and prostate (24,600, with 4,600 deaths). Incidence rates are falling for many cancers but increasing numbers of elderly Canadians mean that the overall numbers of cases will rise, creating more demand for cancer services.

A combination of changing lifestyles, preventive efforts and improved treatment have reduced both incidence and death rates from cardiovascular disease; around 20% of all deaths (around 54,000 per annum) are now attributed to cardiovascular diseases. But because cardiovascular disease affects people who are relatively young, it forms the leading cause of years of life lost to premature mortality. Although heart disease incidence has continued to decline, the aging of the population means that the total numbers of cases has risen slightly, notably during COVID pandemic.

The incidence of diabetes has increased over the past 20 years, but death rates have fluctuated over the past 50 years, without any clear trend. This pattern is plausibly due to improvements in the management of the condition being offset by increases in risk factors such as obesity.

Deaths due to respiratory disease fell from 60 per 100,000 in 1960 to under 40 in 2009, mainly due to improved working conditions and reduced smoking. But the impact of COVID has reversed the decline.

Homicides fell from 2.3 per 100,000 population in 1981 to 1.7 in 2015 but rose to 2.06 per 100,000 in 2021. Deaths due to suicide fluctuate but have risen from 3.5 per 100,000 in 1960 to 11.8 in 2019. The impact of COVID caused a significant increase in suicidal ideation, but final figures are not yet available.

Despite the ever-increasing number of vehicles on the roads, the annual number of deaths from trauma associated with transport fell 69% from 5,933 in 1979 to 1,834 in 2014. In terms of rates, there were 27 transportation deaths per 100,000 population in 1960, 24.6 in 1976 (when seat belt legislation was introduced in Quebec and Ontario), falling to 17.3 in 1986 (by which time legislation was in force in all provinces), then further to 5.2 deaths per 100,000 in 2014. Cars and roads are becoming safer: the fatality rate fell from 1.57 per 10,000 motor vehicles in 2002 to 0.67 in 2021.

Perhaps surprisingly, these improvements in health have not reduced demands on doctors. Ours is an era of rising expectations. The public expects that new treatments will be developed to cure previously untreatable conditions and doctors are called on to broaden the scope of what they treat. Conditions that were previously not regarded as medical problems, such as hyperactivity in children, infertility, weight gain in middle-aged adults, or the various effects of aging now commonly lead patients to consult their doctor; the list is likely to expand.

Dramatic medical advances are exciting, but they bring challenges and raise concerns. First, there are concerns over equity: not everyone has benefitted equally from improvements in health and certain sections of society consistently have poorer health than the average. This has led to calls for action to reduce HEALTH INEQUALITY, discussed in Chapter 2. Second, therapeutic innovations force us to consider the cost implications for a publicly funded, universal health care system (see Chapter 12). Third, there are philosophical implications of the broadening scope of care. Applying medical treatments to palliate problems (such as obesity or type II diabetes) that arise in large measure from lifestyles focuses attention on personal and social accountability. In this complex arena of debate a practical question is raised: what conditions should doctors be expected (and paid) to treat; and hence, how should they be trained?

In partial response, the Royal College of Physicians and Surgeons of Canada published the CanMEDS framework to define competencies that physicians would need, and the roles they should master, in providing the best quality of care in the new millennium1. The physician roles acknowledge that, in addition to being Medical Experts, graduates are also expected to be competent Communicators, Collaborators, Leaders, Health Advocates, Scholars, and Professionals. A far cry from the traditional solo practitioner, the physician has become an agent of a health system, working in a team to treat patients whilst advocating for better policy, gate keeping health resources, continuing his or her education and engaging in research.

Discussions over the boundaries of medicine led to the surprising insight that there is no agreed criterion for defining what constitutes a disease to be treated. The push of supply (whether from companies or from doctors) and the pull of demand (from patients and society) have led us to classify more and more conditions as diseases. The development of Viagra® transformed impotence (which had presumably existed for millennia) from a matter of personal embarrassment into a widely publicized problem for which treatment is routinely prescribed. Broadening the definition of disease brings both benefits and hazards. These were recognized in the 1970s by Ivan Illich, an ex-priest, social critic and polemicist, in his discussion of the “morbid society.”

The “morbid society”

In 1976, Ivan Illich wrote: “Each civilization defines its own diseases. What is sickness in one might be chromosomal abnormality, crime, holiness, or sin in another . . . In a morbid society the belief prevails that defined and diagnosed ill-health is infinitely preferable to any other form of negative label or to no label at all. It is better than criminal or political deviance, better than laziness, better than self-chosen absence from work. More and more people subconsciously know that they are sick and tired of their jobs and of their leisure passivities, but they want to hear the lie that physical illness relieves them of social and political responsibilities. They want their doctor to act as lawyer and priest…”2

“Non-disease”

In 2002, the British Medical Journal led a debate over the appropriate expectations to place on doctors and on how to define the limits of medicine. Richard Smith collected almost 200 examples of “non-diseases”. He defined non-disease as “a human process or problem that some have defined as a medical condition but where people may have better outcomes if the problem or process was not defined in that way.” Examples include burnout, chemical sensitivity, genetic deficiencies, senility, loneliness, bags under the eyes, work problems, baldness, freckles, and jet lag.

Smith’s purpose was to emphasize that disease is a fluid concept with no clear boundaries. He noted various dangers in being over-inclusive in defining disease: when people are diagnosed with a disease and become patients they could be denied insurance, lose their job, have their body invaded in the name of therapy, or be otherwise stigmatised.3  (The debate is covered in the British Medical Journal, April 13, 2002; vol. 324: pages 859-866 and 883-907).

Illness, Sickness, and Disease

In discussing the concept of disease Susser proposed some useful distinctions.4 He used ILLNESS to refer to the subjective sense of feeling unwell; illness does not define a specific pathology, but refers to a person’s subjective experience of it, such as discomfort, tiredness, or general malaise. The way a patient reports symptoms is influenced by his or her cultural background, and SICKNESS refers to socially and culturally held conceptions of health conditions (e.g., the dread of cancer, or the stigma of mental illness or leprosy; see CULTURE, in the Glossary). Cultural conventions likewise affect where the boundary is placed between disease and non-disease: menopause may be considered a health issue in North America, but symptoms are far less commonly reported in Japan.5, 6 DISEASE shifts the focus to pathological processes that may or may not produce symptoms and that result in a patient’s illness. For example, a patient complains of tiredness and malaise – his illness as he experiences it. He consults a doctor because he believes he may be sick. The doctor might attribute the condition to thyroid disease.

Since Louis Pasteur (1822–1895) and the microbiological revolution a “biomedical model” of disease has dominated medical thinking. The focus is on pathological processes and on understanding, diagnosing, and treating the physical and biological aspects of disease. The goal of treatment is to restore the patient’s physiological integrity and function. Diagnosis involves recognizing and applying a label to a pattern of signs and symptoms that is at least partly understood in terms of abnormal structure or function of cells, organs, and systems. This perspective offers a rational basis for the selection of effective treatments. For instance, Paul Richards’s pattern of chest pain, known as angina pectoris, is understood biologically as a disorder of the coronary arteries that causes cardiac ischaemia, and treatments are geared towards restoring cardiac blood flow and reducing cardiac effort.

Early biomedical conceptions supposed that a disease is either present or absent: a bacterium has invaded the body or it has not. However, medicine increasingly tackled conditions, such as hypertension, that represent quantitative deviations from normal values, but what is “normal” is open to debate. Thus, instead of disease being qualitatively distinct from health, many diseases have to be viewed in terms of a threshold on a continuum of biological variability. (More in the Nerd’s Corner box on Alternative definitions of disease). Hypertension can be mild, moderate or severe, or defined as pre-hypertension or hypertension stage 1 or stage 2. Ways of defining a “normal value” are discussed in Chapter 6.

Alternative approaches to defining disease

Basis for defining “disease” Comments
Pathological processes(with or without symptoms; can be detected via diagnostic imaging) It can be difficult to define what “pathological” means, especially in cases of psychological or behavioural disorders. What is the threshold between normal and pathological? This often leads to defining threshold in terms of impact on function: see below.
Abnormal conditions that lead to impaired or altered function at cellular and higher levels This approach sets the threshold for what merits intervention in terms of functional ability: if the person does not complain of loss of function, then it’s not worth bothering with. This may leave some conditions untreated, such as slowly deteriorating eyesight in elderly people.
Illness or sickness that produces unpleasant symptoms See the previous comment; using alternative terms (“illness” or “sickness”) does not really help; again implies that disease must produce symptoms.

Questions to ponder:

  • If it’s asyptomatic, is it a disease? Should we use another term, such as “condition”?
  • Qualitative or quantitative: are health and disease different entities or merely different points along a continuum?
  • If the latter, should we abandon the notion of disease and think only of different levels of health, changing from a categorical to a dimensional model?

Suggestion:

  • Perhaps disease should be defined in terms of a pathological process (physical or mental) that, if left untreated, would naturally progress to producing symptoms and damaging function.
  • Does this make aging a disease? Not necessarily, since many people age and remain healthy. But aging increases the likelihood of disease: it is a risk factor (see Definitions box in Chapter 2).

Disease or syndrome?

As more is learned about the biological basis for an illnesses, it may be reclassified as a disease – we develop an ontology. For example, constant feelings of tiredness became accepted as the medical condition of chronic fatigue syndrome. By formally giving a diagnosis the doctor legitimizes a patient’s complaint and  reassures them.7 Often, however, a set of signs and symptoms eludes biomedical understanding. If the set occurs frequently enough to form a recognised pattern, it is termed a syndrome: a complex of symptoms that occur together more often than would be expected by chance alone. Whereas diseases often receive explanatory labels (such as hemorrhagic stroke), syndromes are often given purely descriptive labels (Restless Leg Syndrome). Confusingly, however, the syndrome label often persists long after the cause is discovered, as with Down syndrome, AIDS (Acquired Immunodeficiency Syndrome) or SARS (Severe Acute Respiratory Syndrome). Meanwhile, others like Chronic Fatigue Syndrome, Fibromyalgia, Irritable Bowel Syndrome, and Restless Leg Syndrome remain syndromic conditions which, so far, are not well explained by conventional biomedical models.

Disease as a Process: Natural History and Clinical Course

The nineteenth-century revolution in thinking brought about by Koch and Pasteur led to the recognition of distinct stages in the development of a disease. If left untreated, a disease would evolve through a series of stages that characterize its NATURAL HISTORY. The dashed line across the diagram indicates that the disease progression may be interrupted at any stage: not all cases progress across the stages. Interventions aim to modify this natural history, producing a characteristic CLINICAL COURSE for the condition. Figure 1.1 represents the concepts of health and disease as processes (rather than states) that unfold over time in a series of steps.

Figure 1.1: The clinical course of a disease, from the biomedical perspective
Figure 1.1: The clinical course of a disease, from the biomedical perspective

After contact with an infectious agent (or following some other physiopathologic event) there is a theoretical point at which the disease process may begin. Symptoms may appear after a delay that can vary from seconds (as with anaphylaxis) to years for some cancers. The patient may interpret their symptoms as indicating an illness and may seek professional care. Shortly after a medical diagnosis, therapy is normally begun and short- and longer-term outcomes can be recorded. If the outcome is unsatisfactory or unexpected there may be a loop back to re-diagnose the condition and alter the therapy, as suggested by the curved line in Figure 1.1. The move towards thinking of disease as a process, rather than a state, required new concepts to describe the stages in this process.

The sequence of disease outcomes

In 1980 the WHO published the International Classification of Impairment, Disability and Handicap (ICIDH), which proposed standard terms for the stages in the clinical course of a disease (see Figure 1.2).8 In this conception, pathology results in IMPAIRMENT, a deviation from normal function in an organ or system. For example, when atherosclerotic plaque narrows coronary arteries, normal cardiac function is impaired and the patient may experience angina. Impairments are not always perceived by the patient, and SCREENING tests may be used to identify impairments of which the person is unaware.

In turn, an impairment can, although need not, lead to a DISABILITY. A disability is defined as “any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.” For instance if Paul Richards’s narrowed arteries cause him chest pain and limit his ability to walk, he has a disability due to heart disease and angina. However, an impairment can often be corrected (medically, surgically or by a prosthesis), so there may be no resulting disability.

In its turn, disability may or may not limit the patient in performing his normal social roles. For instance, severe angina may prevent a patient from working, producing economic, psychological, and social disadvantage in terms of lost income, self-esteem, and social position. HANDICAP is defined as “a disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfillment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual”.  Practical adaptations can prevent a disability from becoming a handicap: finding a desk job for a person with angina of effort, or legislating wheel-chair access to public buildings. But some consequences are harder to compensate: perhaps a 49 year-old patient with intermittent claudication feels he is letting his son down at the annual father-son basketball tournament. Physicians play an important social role in advocating for actions to reduce handicaps for people with disabilities.

Figure 1.2: The WHO impairment, disability, and handicap triad
Figure 1.2: The WHO impairment, disability, and handicap triad

Mapping the hierarchy of disease outcomes


Another sequence in the outcomes of a health problem is called “the five D’s”. The idea was originally proposed by Fries, who listed several possible outcomes of the clinical course of an illness: Discomfort, Disability, Death, Drug toxicity and the Dollar cost of care.9 Subsequent authors have modified the list, often referring to Discomfort, Dysfunction, Disability, Distress, and Death. Whatever terms are used, the idea captures the broad range of impacts of a disease on different patients, and has encouraged physicians to think more broadly than just about a patient’s physical function. We could portray the impacts of a disease along the axes of time and scale (running from cellular to social function) and time, as illustrated in Figure 1.3, below.

Figure 1.3 Connections among disease, illness, disability, sickness, and handicap
Figure 1.3 Connections among disease, illness, disability, sickness, and handicap

The International Classification of Function

Disability and handicap focus on the negative consequences of disease, which may mask the reality that many patients cope very successfully with a chronic condition. In 2001, the WHO proposed more positive phrasing in terms of activities and abilities, resulting in the International Classification of Function, or ICF.10 In this revised classification, “activity” and “participation” replace disability and handicap, further blurring the distinction between health and disease. However, the ICF did more than merely propose new terms; it offered a complete classification system for health states, covering bodily structure and function as these affect the person’s participation in society. It considered contextual factors such as housing, transportation and work that can affect participation; these are among the social determinants of health to be described in Chapter 2. The ICF approaches function as an interaction between a person, his health condition (a disease or injury) and the context in which he lives, including physical environment and cultural norms relevant to the disease.

Selected ICF concepts

Body structures are anatomical parts of the body, such as organs, limbs, and their components
Body functions are the physiological functions of body systems, including psychological functions
Impairments are problems in body structure or function, such as a significant deviation or loss
Activity is the execution of a task or action by an individual
Activity limitations are difficulties an individual may have in executing tasks
Participation is involvement in a life situation
Participation restrictions are problems an individual may have in involvement in life situations
Environmental factors include the physical, social, and attitudinal environments in which people live and conduct their lives. Environmental factors can serve as barriers or as facilitators in a person’s adjustment to impairments.

Two contrasting cases

After seeing Paul Richards, Dr. Rao’s next patient is Mrs. Rebikov, an 86 year-old lady who was diagnosed with colon cancer six years ago after presenting with a bowel obstruction. Mrs. Rebikov was always a vigorous woman; she recovered quickly from her bowel resection and even said she enjoyed going in to Weenigo for her chemotherapy because it gave her a chance to browse in a good bookstore. But Mrs. Rebikov’s cancer has progressed to the point where she now receives palliative care only. She is currently writing about her experience of cancer for the Goosefoot Times. Dr. Rao can’t help feeling that Mrs. Rebikov is much healthier that Paul Richards.

Dr. Rao ponders these two cases; merely to say that each has a serious disease does not capture the complexities. For many reasons, Paul’s disease has led to disability and handicap whereas Mrs. Rebikov seems to be experiencing surprisingly good health and is still able to participate in society despite her fatal condition.

Definitions of Health

Defining health seems even more elusive than defining disease and definitions have evolved over time. In keeping with the biomedical perspective, early definitions focused on the body’s ability to function; health was seen as a state of normal function which could be disrupted from time to time by disease. An example of such a definition of health is: “a state characterized by anatomic, physiologic, and psychological integrity; ability to perform personally valued family, work, and community roles; ability to deal with physical, biologic, psychological, and social stress”.11

Then, in 1948 the WHO responded to the rising expectations for health, and proposed a more positive definition, linking health to well-being in the phrase “physical, mental, and social well-being, and not merely the absence of disease and infirmity”.12 Although this definition was welcomed by some as an exciting innovation, it was also criticized as being vague, excessively broad, and probably unmeasurable. For a long time it was set aside as an impractical ideal and most discussions of health returned to the practicality of the biomedical model. Then, just as there was a shift from viewing disease as a state to thinking of it as an interactive process, a similar shift was made in defining health. Again, the WHO played a leading role when it fostered the development of the health promotion movement in the 1980s. This approached health not as a state, but in dynamic terms of capacity and performance, as “a resource for living”.13 In 1984 the WHO defined health as “the extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources, as well as physical capacities”.14

Evolving conceptions of health

In 1977, psychiatrist George Engel had presented the idea of health as a capacity under the less than riveting title of the biopsychosocial model of health.15 He portrayed disease as the body’s physiological responses to demanding environmental or social triggers; like Susser, Engel saw illness in terms of the patient’s interpretation of symptoms. This interpretation was influenced by the patient’s beliefs and personal relationships, both of which confer resiliency, so are components of health. He thereby presented health and disease as not merely a continuum along which an individual is situated at any moment, but as a form of interaction between the opposing forces of stimulus or challenge and coping response. Much earlier, Freud had spoken of health as the capacity to love and to work (a view that appeals to some medical students). A person who has the capacity to do what he chooses is healthy; this represented an early shift from an absolute definition to a relative and subjective one. It aligned health with notions of freedom and the quality of life, and represented a shift from viewing health objectively from the outside to adopting the individual’s subjective perspective.

A corollary is that a patient may have a serious disease yet perceive himself as reasonably healthy if he can still do what he desires to do. Health can be viewed in terms of adjustment to reality; para-olympians are healthy. Similarly, the notion of healthy aging may be defined as a person’s adaptation to the natural decline in their faculties, as living in balance with their capacities. The process whereby people trim their expectations to match their declining health, so maintain satisfaction with life, is termed “response shift”.16

Wellness

This chapter opened with the themes of rising aspirations and the resulting reconceptualization of disease and health. In consequence, many practitioners have expanded their focus to include maintaining a patient’s wellness at the positive end of the health continuum. Some distinguish two interacting dimensions: disease versus non-disease and well-being versus ill-being; others expand the number of dimensions to include spiritual, emotional, social, and mental wellness. Last commented that wellness is “a word used by behavioural scientists to describe a state of dynamic physical, mental, social, and spiritual well-being that enables a person to achieve full potential and an enjoyable life”.17

But with so much disease to treat, should physicians concern themselves with wellness? Is it appropriate for medicine to seek ways to promote positive health states? Some academics distinguish between a medical care system and a health care system, arguing that, to constrain costs, public funding should be limited to treating illness and restoring the patient’s functional capacity. Others broaden this to note that activities such as patient counselling and educating healthy individuals on diet and exercise promote wellness and resiliency, and so fall within the scope of preventive medicine. Some go further and argue that physicians should advocate for changing health determinants by improving work conditions, promoting active transportation and supporting policies that redistribute income. This echoes the social well-being component of health implied in the 1984 WHO definition, and is captured in the CanMEDS physician roles. As concepts of health and disease broaden, there is pressure for physicians to expand their role to include the promotion of positive quality of life for their patients. Reflecting this, clinical trials evaluating new pharmaceuticals must now include improved quality of life as an outcome, beyond simply improving biomedical indicators of pathology.

Discussions of wellness eroded the hold of the BIOMEDICAL MODEL. In its place, ecological models of health were proposed; these recognize the complex interactions among people, their personal characteristics and the environment as relevant aspects of health and disease. An example of this thinking was provided by Trevor Hancock’s “mandala of health”.18 This links individual health to a community ecosystem of nested determinants, beginning with the person at the centre (distinguishing body, mind, and spirit), then moving outwards to the social and physical environment, and then further out to culture, economic, and societal influences. The mandala is intended to draw attention to the wide range of health determinants that need to be addressed by strategies for improving health.

Figure 1.4: The Mandala of Health.
Figure 1.4: The Mandala of Health.

Subsequently, the global health perspective added further rings to the diagram to represent the health influences of global climate, economic processes, wars, culture, and the impact of travel in quickly spreading disease. We return to these social determinants of health in Chapter 2. An extension of the mandala that includes a time dimension is the integrated life course and social determinants model of Aboriginal health proposed by Reading and Wein (Figure 1.5).19, p26 This model represents health influences as a set of concentric spheres (the cut-away allows the inner spheres to be seen). The child is at the centre, youth and adulthood experiences in surrounding spheres, with successive layers of determinants outside of these. The inner spheres are segmented to represent the mental, physical, emotional, and spiritual aspects of health.19, p26

Figure 1.4: Integrated life course and social determinants model of Aboriginal health19
Figure 1.5: Integrated life course and social determinants model of Aboriginal health19

Spiritual health and Canadian Indigenous healing traditions

The broadening conceptions of health challenged the traditional western Cartesian tradition of separating mind and body (see Nerd’s Corner box on Descartes). Rising aspirations for health, combined with the challenge of treating mental illness, has raised the profile of medical traditions from other cultures. These commonly emphasize healing rather than treating, and focus attention on the patient’s spirit as well as their body. Spiritual health may be indicated by a sense of peace, hope, purpose, commitment, or worth. Some people find spirituality through religious practice, while others find it in connection with their values, or through nature, mindfulness, art, or music. A physician who recognizes the relevance of spiritual health may be better able to support her patients, bringing a sense of peace, comfort, strength, love, or connection in order to improve the patient’s sense of well-being.20 For example, chemical dependence is increasingly being recognized as having biological, psychological, social and spiritual dimensions.

Descartes

Before the French mathematician and philosopher René Descartes (1596–1650), explanations for the observed world were based on a mix of religious beliefs and potentially biased interpretations of observations. Descartes pioneered the open-minded scepticism that characterizes modern science; he began by rejecting all forms of preconception and belief. Science had to consider only what was observable, and the mind was not. Descartes argued that our senses could not be trusted as accurate sources of information, so he proposed a rigid division between mind and body: the Cartesian dualism.

As an example of a challenge to Cartesian dualism, First Nations, Inuit and Métis indigenous traditions have  long recognized other, non-physical dimensions of health.21, 22 Their teachings take a broad ecological approach, and consider health in terms of a balance of the spiritual, emotional, physical and intellectual dimensions of a person. Healing is achieved by restoring balance and healing relationships are based on respect, humility, compassion, truth, sharing, hospitality, and divine love.23 These ideas are symbolized in various ways by different indigenous groups: by the medicine wheel, the learning blanket or the Métis tree model of Holistic Lifelong Learning (see Illustrations box).24

Indigenous metaphors for health

For many First Nations, the medicine wheel symbolizes the interconnection of all life, the various cycles of nature, and how life represents a circular journey (see an illustration).

The four quadrants can represent many things:

1) The four cardinal points, each with a guiding spirit, symbolizing stages in the life journey. The East, the daily birthplace of the sun, represents a person’s early years. The South relates to childhood and intellectual growth. The West symbolizes adulthood and introspection, while the North represents the old age, wisdom, and the spiritual aspects of life. Mother Earth and the Creator lie at the centre of the wheel.

2) The four points can represent the balance between four aspects of health: spiritual (East), emotional (South), physical (West), and mental (North).

3) The wheel can also represent the process of making decisions. Values (represented by the East, where the sun rises) guide decisions taken in the mental realm (placed in the North, at the top). Then, decisions are implemented in the physical realm (West), and actions produce reactions in the emotional realm (South). These reactions feed back into the value system, completing the circle of value, decision, action, and evaluation.

4) The wheel can represent the Four Sacred Medicines:
Tobacco (the East) is a scared plant that connects people to the spirit world; it absorbs prayers and carries them to the spirit world and thanks the Creator for his gifts.
Cedar (the South) is used for purification and (taken as a tea) to attract positive energy and emotions, as well as for balance. Its vitamin C content helped prevent scurvy when fruits and vegetables were unavailable during the winter months.
Sage (the West) is a medicine for women, conferring strength, wisdom, and clarity of purpose. Sage can be found braided and hung in people’s homes; the braid represents body, mind, and spirit.
Sweetgrass (the North) used for ritual cleansing, and represents virtue.

The Inuit learning blanket
A colourful, circular blanket portrays scenes from Inuit life that symbolize the sources of learning and domains of knowledge—culture, traditions, people, and the life force that derives from the people’s relationship with their environment. These are illustrated on the blanket by images drawn from Inuit life. The blanket’s circular shape represents the interconnectedness of all life forms, and the continuous cycle of life, death and regeneration that links past, present and future. Various images of the blanket can be found on the web.

The Métis holistic lifelong learning model
Various conceptions of health exist among different Métis groups. Some groups view life as a learning process and part of a regenerative, organic system, a natural order that they symbolize by a forest of trees. Tree roots represent the individual’s health, nurturing lifelong learning. The trunk contains the growth rings with spiritual health at the core, expanding outwards to the emotional, physical, and mental dimensions of the Métis identity. These rings evolve over the life course. As wisdom is gained, new branches represent different sources: self, other people, the land, and traditions.

In recognition of the relevance of Indigenous concepts of health and healing, the Indigenous Physicians Association of Canada (IPAC) and the Association of Faculties of Medicine of Canada (AFMC) created a set of competency standards for medical students working with First Nations, Inuit, and Métis patients. The competencies are structured around the CanMEDS physician roles and guide students in developing culturally safe practice when engaging with First Nations, Inuit, and Métis patients. They are available on the AFMC web site.

Integrative Medicine

This chapter has reviewed various challenges to Western biomedical or allopathic approaches (see Nerd’s Corner “Allopathic Medicine”). One response has been to propose “integrative medicine”25 as a collaboration between biomedical approaches and other healing traditions, including herbal remedies, manual interventions such as massage therapy or chiropractic, and mind-body practices such as hypnosis. Similarly, the Canadian College of Naturopathic Medicine trains naturopathic doctors who employ natural therapies as well as using the more standard medical diagnoses of allopathic medicine.

Allopathic medicine

In pre-enlightenment cultures, medicine was based on a mix of magic, religion, and empirically tested folk remedies. But as belief in magic and superstition declined in Europe during the Middle Ages, medicine sought a new basis; this had to be something active that would impress patients, a substitute for the incense and incantations that sceptics no longer respected. The answer, to be much later named allopathy, had been developed long before, in the Middle East around the first century B.C. The idea was simple: when the body’s workings deviate from the normal, the doctor should try to restore normal function. A man with a fever should be cooled; if constipated, given a laxative. Illnesses were seen as caused by toxins that should be eliminated. This led to therapies such as bleeding, leeches, enemas, and purgatives. Interventions were often harsh, as depicted cynically in Molière’s plays, and a war metaphor took hold: patients “battle disease;” doctors “wage war” on pathogens and both “join forces to fight cancer”. Note that in French, alternative (i.e., non-allopathic) therapies are called médecine douce, or gentle medicine. The term allopathy was coined by Samuel Hahnemann, who founded homeopathy. Whereas allopathy implies opposing the symptoms of disease, homoepathy implies working with the disease by stimulating the body to produce its natural defensive (e.g., immune) responses.

For a time during the mid-nineteenth century, homeopathy (treating like with like) was a serious rival to the allopathic approach, but the development of the germ theory provided allopathy with a scientific foundation for many of its remedies. However, by the mid twentieth century disillusionment began when, despite advances in “the conquest of infectious disease”, hospitals remained full and waiting lists stayed long. This may have reflected a rising demand for treatments induced by their success, but the very success of allopathic medicine (along with improved social conditions) enabled people to live long enough to suffer degenerative diseases for which the allopathic approach is less effective. Moreover, undesired consequences include growing costs and the problem of iatrogenic disorders.2 While allopathic remedies are often highly effective, integrative practitioners are borrowing ideas from non-allopathic treatments and accept that the best cure may often be for the patient to restore balance in their life and get adequate sleep, exercise, and good nutrition.

In the words of Rakel and Weil, the integrative medicine approach involves “developing insight into the patient’s culture, beliefs, and lifestyle” so as to “trigger the necessary changes in behaviour that will result in improved health.” This requires understanding the underlying determinants of health and how they may be modified using the tools of behavior change and of public and population health interventions. “Integrative medicine is about changing the focus in medicine to one of healing rather than disease. This involves an understanding of the influences of mind, spirit, and community as well as of the body. It entails developing insight into the patient’s culture, beliefs, and lifestyle that will help the provider understand how best to trigger the necessary changes in behaviour that will result in improved health”. 25, p6  These ideas form the core themes of Chapter 2.

Reflection Questions

  1. What definitions of health do you prefer?
  2. How would you know if someone is healthy or not?
  3. If a pathogen lies dormant in a person’s body (a herpes virus, for example) does the person have a disease? Or, does it only become a disease when symptoms appear (such as shingles)?
  4. How do you distinguish between disease and injury?
  5. How should society establish a balance between preserving freedom to choose how we live, versus taking responsibility for health? Some may uphold a person’s right to act in a way that could damage his health, but all taxpayers pay for the medical bills that this behaviour entails, and this forms an opportunity cost to everyone: those taxes could have been spent on something that might have benefited more people.
  6. Addiction is now considered a disease, so should we excuse the anti-social behaviour of a drug addict because they have a medical problem?
  7. How would you describe your approach to helping a patient whose lifestyle has caused their medical condition, balanced between holding them responsible for their fate versus rejecting this as an example of “blaming the victim”?
  8. Give examples of the way in which social environments impact someone’s health. Then, do the same for urban environments.
  9. Back in the 1950s, Talcott Parsons described “the sick role” as including behaviours that were acceptable for someone who is sick, but not for someone who is well. They included things such as lying in bed instead of going to work, having someone cook for you, etc. What behaviours would you consider appropriate for a person who is ill in the modern era? How may this vary across socio-economic strata and across cultural groups?
  10. If a drug for rheumatoid arthritis causes a change in sedimentation rate or rheumatoid factor (indicators of disease activity) but has no detectable effects on the quality of life of those who take it, is it an effective drug?

Self-Test Questions

1. How has the World Health Organization’s definition of health evolved over time?

The main change was in moving from a “state of well-being” which seemed a bit static, to seeing health as a capacity to respond to challenges: a “resource for everyday life”.

2. What are key dimensions of health?

There is little dispute over physical, mental and social dimensions. The social is harder to describe than the others; it often refers to the capacity to establish and maintain social bonds and to interact successfully with others. Some authors include dimensions referring to spirituality, in the sense of being at ease with one’s destiny or at peace with oneself.

3. Name one difference between a traditional biomedical definition of health and a traditional conception from an Indigenous group with which you are familiar.

Breadth: the Aboriginal conception includes the spiritual dimension; biomedical focus on pathology and disease versus on the positive aspects of well-being; biomedical focus on treating illness versus on healing the person; eliminating pathogens versus establishing balance, etc.

4. Distinguish between illness and disease.

Perspective: what the patient experiences versus the physician’s interpretation of symptoms and signs.

5. List levels at which social environments impact health according to an ecological model.

Often illustrated via concentric circles radiating outward from the person. For example, family and close friends who influence their feelings and behaviours; their work or school context that may create stresses; their community, province and region that influence the quality of care they receive; government that legislates matters such as safety standards; the nation that decides on major issues such as going to war or tackling climate change, and global issues that affect health via patterns of climate or travel that can affect health via transmission of infectious diseases.

6. What is illness behaviour?

The pattern of reactions a patient has to their perception of being unwell, including whether or not to seek care, and how far to comply with the doctor’s recommendations if care is sought. These reactions vary from culture to culture and also according to personality: no two patients respond the same way!

7. Illustrate ways in which a person’s culture may affect their approach to accessing health care.

First, via differing conceptions of what is considered a “disease” meriting attention. Second, in terms of how one should respond to symptoms (take medication or not; follow a doctor’s advice or grandmother’s?). Third, in the emotional reaction to a diagnosis; fourth, in terms of acceptance of different forms of treatment, including whole systems of medicine: acupuncture or Ayurveda versus western medicine

References

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