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CONCEPTS OF
HEALTH AND
ILLNESS

Adapted from Chapter 1 of the AFMC Primer

found at http://phprimer.afmc.ca

September 2016
OBJECTIVES THE WIDENING SCOPE OF MEDICINE
A1.1c Provide exam- Over the past half-century, the Canadian population has seen unprece-
ples of disease preven- dented gains in longevity, health, and well-being. Improvements in the
tion and the promotion environment and in health policies, changing lifestyles and therapeutic
of healthy behaviours in advances have all contributed to enhancing the length and quality of
clinical practice. life. We can now expect to live into our 80s, and ours is an era of rising
expectations. The public confidently expects that new treatments will
• Define and discuss be developed to cure previously untreatable conditions. Patients ex-
the concepts of
pect faster access to health care to deliver these treatments, and more
health, wellness, ill-
complete information about them.
ness, disease and
sickness  Perhaps surprisingly, the improvements in health have not reduced the
demands on doctors. Instead, doctors are called on to broaden the
• Discuss alternative scope of what they treat. Conditions, previously not regarded as medi-
definitions of health
cal problems, such as hyperactivity in children, infertility in young cou-
• Demonstrate the role ples, weight gain in middle-aged adults, or the various natural effects of
that physicians can aging, now commonly lead patients to consult their doctor; the list is
play in promoting likely to expand.
health and preventing
Dramatic medical advances are exciting, but they bring challenges and
diseases at the indi-
have raised concerns. First, there are concerns over equity: not every-
vidual and community
one has benefitted equally from improvements in health and identifiable
level
sections of society consistently have poorer health than the average.
• Discuss the concepts This has led to calls for action to reduce health inequalities. Second,
of life course and therapeutic innovations force us to consider the cost implications for a
natural history of dis- publicly funded, universal health care system. Third, as well as financial
ease, particularly with concerns, there are philosophical implications of the broadening scope
respect to possible of care. Applying medical treatments to palliate avoidable problems
public health and clini- (such as obesity or type II diabetes) that arise in large measure from
cal interventions lifestyles focuses attention on 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 in the 1990s to define com-
petencies that physicians would need, and roles they should master, in
providing the best quality of care in the new millennium. The physician
roles acknowledge that, in addition to being medical experts, gradu-
ates are also expected to be competent as communicators, collabora-

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tors, managers, health advocates, scholars, and professionals. As Queen’s medical students, you will
become familiar with our local adaptation of this framework embodied in our Curricular Goals and Ob-
jectives (known as the “red book”). A far cry from the traditional solo practitioner engaged in long-
term caring relationships with his patients, the physician has become an agent of health whose work
involves treating patients, advocating for better policy, gate keeping health resources and attending
conferences and engaging in research.

Discussions over setting appropriate boundaries for medicine led to the surprising insight that there
is no agreed criterion for defining what constitutes a disease. The push of supply (whether from com-
panies or from doctors) and the pull of demand (from patients and society) have led us to classify
more and more common 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
has benefits but may also have disadvantages.

ILLNESS, SICKNESS AND DISEASE

Discussing the complexities of what constitutes a disease requires careful distinction among related,
but distinct concepts. In 1973, Susser, an epidemiologist, proposed some definitions that remain use-
ful.

Illness is the subjective sense of feeling unwell; illness does not define a specific pathology, but re-
fers to a person’s subjective experience of it, such as discomfort, tiredness, or general malaise.

Sickness refers to socially and culturally held conceptions of health conditions (e.g., the dread of
cancer or the stigma of mental illness), which in turn influence how the patient reacts. The social per-
ceptions of disease modify the ways a patient perceives and presents his symptoms. Cultural conven-
tions likewise affect where the boundary between disease and non-disease is placed: menopause
may be considered a health issue in North America, but symptoms are far less commonly reported in
Japan.

Disease implies a focus on 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 about it because he believes that he might have a sickness.
The doctor might attribute the patient’s symptoms to a thyroid condition a disease.

The biomedical model of disease has dominated medical thinking since the time of Louis Pasteur
(1822-1895) and the microbiological revolution. This model focuses 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 recogniz-
ing 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 offers a rational basis for

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the investigation of effective treatments. For instance, a certain pattern of chest pain known as angina
pectoris is understood biologically as a disorder of the coronary arteries that causes cardiac ische-
mia, and the treatments are geared to the specific causes of restoring cardiac blood flow and reduc-
ing 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, as medicine increasingly tackled conditions, such as hyper-
tension, which represent deviations from normal values, which themselves have a range and can be
debated, it became apparent that there may be no set threshold for defining disease. Thus, instead
of being seen as a state that is qualitatively distinct from health, many diseases have to be ap-
proached as a quantitative threshold on a continuum of biological variability. Organizations such as
the World Health Organization (WHO) and the National Institutes of Health have proposed different
classifications of hypertension and have changed how they constitute hypertension over time.

DISEASE OR SYNDROME?
As we learn more about the biological basis for a patient’s illness, it may be reclassified as a disease.
For example, constant feelings of tiredness became accepted as the medical condition of chronic fa-
tigue syndrome. Sometimes when a doctor formally labels (diagnoses) a patient’s complaint, the com-
plaint is legitimized and this may reassure the patient. Often, however, a set of signs and symptoms
eludes biomedical understanding. If the set is frequent enough to be a recognized pattern, it is
termed a syndrome instead of a disease. A syndrome refers to a complex of symptoms that occur to-
gether more often than would be expected by chance alone. Whereas diseases often receive ex-
planatory labels (such as hemorrhagic stroke), syndromes are often given purely descriptive labels
(e.g., Restless Leg Syndrome). Confusingly, the label ‘syndrome’ often persists long after the cause is
discovered, as with Down syndrome, AIDS (Acquired Immunodeficiency Syndrome) or SARS (Severe
Acute Respiratory Syndrome). Meanwhile, Chronic Fatigue Syndrome, Fibromyalgia, Irritable Bowel
Syndrome, and Restless Leg Syndrome remain syndromic conditions which, so far, are not well ex-
plained 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 recogni-
tion 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. But if an intervention is applied, the
natural history is modified, producing a typical clinical course for the condition. Figure 1.1 represents
the concept of health and disease as processes (rather than states) that unfold over time in a series
of steps. The dashed line in the centre of the diagram indicates that the disease progression may be
interrupted at any stage. It’s important to note that not all cases progress across all the stages.

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Figure 1.1: The clinical After contact with an infectious agent (or following some other patho-
course of a disease, physiologic event) there is a theoretical point at which the disease proc-
from the biomedical ess may begin. Symptoms may appear after a delay that can vary from
perspective seconds (as with anaphylaxis) to years (as with some cancers). The pa-
tient may interpret their symptoms as indicating an illness and may
seek professional care. Shortly after a medical diagnosis, therapy is nor-
mally 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
pink curved line. 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 Impair-
ment, Disability and Handicap (ICIDH), which proposed standard terms
for the stages in the clinical course of a disease (see Figure 1.2). In this
conception, pathology produces some form of disease and results in
impairment, a deviation from normal function in an organ or system.
For example, when atherosclerotic plaque narrows coronary arteries,
the patient may experience angina and normal cardiac function is im-

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paired. Impairments are not always perceived by the patient, and screening tests are used to identify
impairments of which the person is not aware.

In turn, an impairment can, although does not necessarily, 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 a man with narrowed arter-
ies cause him chest pain and if this limits 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 prosthe-
sis), 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 in-
stance, severe angina may prevent a patient from working, producing social, psychological, and eco-
nomic hardships 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." Handicap relates the impact of a disease to the social roles of the person with it. Practical
interventions can prevent a disability from becoming a handicap: finding a desk job for a person with
angina of effort, or making buildings wheel-chair accessible for people with mobility problems. But
some consequences are harder to compensate: perhaps a 49-year-old patient with intermittent claudi-
cation no longer feels like "one of the guys" since he can no longer kick the soccer ball with them on
Sunday or feels he is letting his son down at the annual father-son two-on-two basketball tournament.
Because they are hard to correct, social and psychological sequelae are often overlooked.

THE INTERNATIONAL CLASSIFICATION OF FUNCTION

Concepts such as disability and handicap focus on the negative consequences of disease, and may
mask the reality that many people cope very successfully with their condition. In 2001, the WHO pro-
posed more positive phrasing in terms of activities and abilities, resulting in the International Classifi-
cation of Function, or ICF. In this revised classification, ‘activity’ and ‘participation’ replace ‘disability’
and ‘handicap’, which further blurs the distinction between health and disease. However, the ICF
goes beyond merely proposing new terms; it forms a complete classification system for health states,
covering body structures and functions, impairments, activities, and the person’s participation in soci-
ety. It also considers contextual factors such as housing, transportation and work that can affect activ-
ity levels; these are some of the social determinants of health. In other words, function is viewed as
an interaction between a person’s health condition (such as a disease or injury) and the context in
which he or she lives, including physical environment and cultural norms relevant to the disease. As
an international project, the ICF establishes a common language for describing states of health for
comparative analyses across diseases and countries.

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 DEFINITIONS OF HEALTH
If there are complexities in defining disease, there are even more in de-
fining health. Definitions have evolved over time. In keeping with the bio-
medical perspective, early definitions of health focused on the theme of
the body’s ability to function; health was seen as a state of normal func-
tion that 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".  Then, in 1948, in a radical
departure from previous definitions, the WHO proposed a definition that
aimed higher, linking health to well-being, in terms of "physical, mental,
Figure 1.2: The WHO and social well-being, and not merely the absence of disease and
impairment, disability, infirmity". Although this definition was welcomed by some as being inno-
and handicap triad

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vative and exciting, it was also criticized as being vague, excessively broad, and 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.

HEALTH AS A RESOURCE
Just as there was a shift from viewing disease as a state to thinking of it as a process, the same shift
happened in definitions of health. Again, the WHO played a leading role when it fostered the develop-
ment of the health promotion movement in the 1980s. This brought in a new conception of health,
not as a state, but in dynamic terms of resiliency, in other words, as "a resource for living". The 1984
WHO revised definition of health defined it as "the extent to which an individual or group is able to re-
alize 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". Thus, health referred to the ability to maintain homeostasis
and recover from insults. Mental, intellectual, emotional, and social health referred to a person’s abil-
ity to handle stress, to acquire skills, to maintain relationships, all of which form resources for resil-
iency and independent living.

WELLNESS
This chapter opened with the theme of rising aspirations and the resulting reconceptualization of dis-
ease and health. In response, many practitioners have expanded their focus to include wellness at
the positive end of the health continuum. Some distinguish two interacting dimensions: disease ver-
sus non-disease and well-being versus ill-being; others expand the number of dimensions to include
spiritual, emotional, social, and mental. 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 en-
ables a person to achieve full potential and an enjoyable life".

But with so much disease to treat, should physicians concern themselves with wellness? Is it appropri-
ate for medicine to seek ways to promote positive health states? Some academics distinguish be-
tween a medical care system and a health care system, arguing that, to constrain costs, public fund-
ing should be limited to treating illness and restoring the patient’s functional capacity. Others note
that activities such as counselling and educating healthy individuals on diet and exercise promote
wellness and resiliency, and so fall within the scope of normal practice as a part of preventive medi-
cine. Some go further and argue that physicians should advocate for improved work and environ-
mental conditions, such as promoting walking and cycling rather than driving, and should advocate
for policies that redistribute income, limit access to unhealthy foods, and support children’s pro-
grams. As concepts of health and disease continue to broaden, there will no doubt be pressure for
physicians to expand their role to include the promotion of positive health states in their patients. Re-
flecting this trend, clinical trials evaluating new pharmaceuticals must now include improved quality

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of life as an outcome, which obviously extends beyond simply improving biomedical indicators of pa-
thology.

Discussions of wellness eroded the hold of the biomedical model. In its place, ecological models of
health appeared; these recognize the complex interactions among people, their personal characteris-
tics and the environment, and how these influence health. An example of this thinking was provided
by Trevor Hancock in his ‘mandala of health’. This is a model of health and the community ecosystem
that represents health determinants as concentric nested influences, beginning with the person at the
centre (distinguishing body, mind, and spirit), then moving outwards to the social and physical envi-
ronment, and then moving further out to culture, economic, and societal influences. The mandala is
intended to draw attention to the wide range of health determinants. More recently, a global health
perspective has added further rings to the concentric circles to represent the health influences of
global climate, economic processes, wars, culture, and the impact of travel in quickly spreading dis-
ease.

PUBLIC AND POPULATION HEALTH

While public health is a familiar term, it can be difficult to give it a single precise definition. Its gen-
eral focus is on preventing disease and protecting health:

"Public health is defined as the organized efforts of society to keep people healthy and prevent injury,
illness, and premature death. It is a combination of programs, services, and policies that protect and
promote the health of all Canadians".

But this definition does not give us a clear picture of what is, and what is not, included. In part the dif-
ficulty arises because public health does not concern a specific organ system, type of disease or
therapeutic approach, but employs a variety of approaches to address whatever health issues are
most pressing in each place and time. The discipline has seen a succession of names as it wrestled
with whether environmental factors, or individual behaviour, or societal policies should form the main
focus of interventions.

As population health is a relatively new concept, uncertainties remain over details of how, precisely,
it differs from public health. Both are concerned with patterns of health and illness in groups of peo-
ple rather than in individuals; both monitor health trends, examine their determinants, propose inter-
ventions at the population level to protect and promote health, and discuss options for delivering
these interventions. The distinction is subtle, but population health is seen as broader, as offering a
unifying paradigm that links disciplines from the biological to the sociological. It provides a rational
basis for allocating health resources that balances health protection and promotion against illness
prevention and treatment, while also making a significant contribution to basic science. When public
health tackles a health issue, its interventions are focused on maintaining health or preventing dis-
ease. For example, the public health approach to childhood obesity might advocate education for

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 parents and children, subsidized healthy school lunch programs, ban-
ning soft drinks in school vending machines, tougher regulations on
marketing of junk food to children, promoting physical activity, etc. A
population health approach would tackle childhood obesity in a
broader context. A population health approach might be to consider
the food system itself: how do agricultural subsidies affect the price of
food? Can city planning policies prevent the problem of urban food de-
serts where significant areas of the population lack access to a grocery
store? Public health focuses on prevention and health protection serv-
ices, whereas the population health approach is somewhat broader. It
still values "health" as a key outcome, but views issues from a broader
perspective and tends to include additional considerations, such as
economics, environmental sustainability, social justice, etc.

Figure 1.3 The

Mandala of Health

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Although, in general, physicians treat individual patients and not populations, for several reasons it is
important that they are aware of patterns of illness in the population being served. First, although a
medical condition may result from the patient’s lifestyle, the driving forces for this lifestyle lie in the so-
cial environment. Second, the old chestnut of medical teaching "common things are common" is true:
in effect, the patient’s condition is a symptom of population-wide health patterns. The underlying
population prevalence will therefore affect the hierarchy of a doctor’s differential diagnoses. In Can-
ada, chest pain in a 50-year-old male is more likely to be of cardiac origin than an identical complaint
in a 15-year-old female. Third, because of the social context in which a patient lives, efforts to help
him alter health behaviours may be frustrated by the social pressures he experiences. Hence, it may
prove more efficient to tackle a disease at the population level (e.g., by lobbying for taxation on high-
fat foods, then using the proceeds to subsidize exercise programs) than by treating large numbers of
individuals

Reflecting a population health approach, the College of Physicians and Surgeons of Canada de-
scribed the role of physicians as health advocates: "As Health Advocates, physicians responsibly use
their expertise and influence to advance the health and well-being of individual patients, communi-
ties, and populations". and to the need to address many levels in developing strategies for improving
health.

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