Understanding Health and Illness

25 min

Who is healthy?

Consider three people:

Mukamana, 52, has had type 2 diabetes for ten years. She checks her blood sugar, walks to the market every day, leads her savings group and says she feels well.
Eric, 19, has no diagnosed disease, but has felt low and exhausted for months, has stopped seeing friends and is struggling to study.
Gasana, 30, feels perfectly well. He does not know that his blood pressure is dangerously high.

A doctor might call Eric and Gasana "healthy" and Mukamana "ill". Each of them might answer differently. The puzzle shows that health is harder to define than it seems, and that a person's experience can differ from a medical diagnosis.

Definition

Health (World Health Organization, 1948): "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

Mental health (WHO, 2022): "a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community."

Disease: a biological or physiological malfunction that can be identified by medical examination or tests, such as high blood pressure.

Illness: the person's own experience of being unwell: symptoms, suffering and how life is affected.

Sickness: the social side of being unwell: being recognised by others as ill and given a different role, such as time off school.

1. Disease, illness and sickness

Medical sociologists and anthropologists (for example Andrew Twaddle, 1968, and Arthur Kleinman, 1988) separate these three meanings because they do not always go together:

Person	Disease?	Illness?	Sickness?
Gasana (undiagnosed high blood pressure)	Yes	No: he feels well	No: nobody treats him as ill
Eric (low mood, exhaustion, not yet assessed)	Not yet identified	Yes: he suffers	Perhaps not: others may call him lazy
Mukamana (well-managed diabetes)	Yes	Mostly no	Partly: she has regular clinic visits

Eric's case shows why the distinction matters. When a person's suffering is not recognised as illness, he or she may be blamed instead of helped. Low mood and exhaustion that last for weeks deserve to be taken seriously and assessed at a health centre, just like a physical complaint.

2. Evaluating the WHO definition

Strengths. It was revolutionary in 1948: it made health positive (well-being, not only the absence of disease) and included mental and social health, not only the body.
"Complete" is too strict. Almost nobody is in a state of complete well-being, so almost everybody would be unhealthy. Machteld Huber and colleagues (2011) proposed defining health instead as "the ability to adapt and to self-manage" in the face of social, physical and emotional challenges, which fits Mukamana well.
Chronic conditions. As people live longer, many live well for decades with a long-term condition. A definition that labels them all unhealthy is not helpful.
Culture. Many communities, including in Rwanda, understand health as harmony in a person's relationships with family, community and spiritual life, not only as a state of the individual body. The WHO definition's "social well-being" partly captures this.

3. Health as a continuum

Rather than two boxes, "healthy" and "ill", many health psychologists picture a continuum. John Travis (1972) drew an illness–wellness continuum with a neutral point in the middle (Figure 1). Treatment can move a person from the illness side back to neutral, but moving further towards high-level wellness needs awareness, learning and growth. Aaron Antonovsky's idea of salutogenesis (1979) similarly asks not only what makes people ill, but what keeps them well, such as a "sense of coherence": seeing life as understandable, manageable and meaningful.

4. Dimensions of well-being

Health psychologists usually look at several linked dimensions: physical (the body's functioning, fitness, sleep, nutrition), mental and emotional (mood, coping, self-esteem), social (relationships, belonging, support), and for many people spiritual (meaning, values, faith). A problem in one dimension often affects the others: long-term pain can lower mood, and loneliness can affect sleep and blood pressure.

Warning

"Mental illness" is not a weakness or a choice. Mental health conditions are health conditions. Like physical illnesses, they have biological, psychological and social causes, and they can be treated. Use respectful language: "a person living with depression", not a label that reduces someone to a condition.

Tip

D-I-S: Disease is what the doctor finds; Illness is what the person feels; Sickness is how society treats the person. In an exam scenario, check all three.

Important

Discuss. Is Mukamana healthy? Answer using the WHO definition, then Huber's "ability to adapt and to self-manage", and then Travis's continuum. Which definition do you find most useful, and why?

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Practice

Quote the WHO (1948) definition of health.
Distinguish between disease, illness and sickness.
Give one example of a person who has a disease but no illness, and one who has an illness that is not yet recognised as a disease.
State two strengths and two criticisms of the WHO definition.
Explain the illness–wellness continuum. What is the difference between treatment and wellness on it?
Explain how a problem in the social dimension of health could affect the physical dimension.
Evaluate the claim that "health is simply the absence of disease".

Show answersHide answers

"A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
Disease: a biological malfunction identified by medicine. Illness: the person's subjective experience of being unwell. Sickness: the social recognition of illness and the role that goes with it.
Disease without illness: undiagnosed high blood pressure in someone who feels well. Illness not yet recognised as disease: months of low mood and exhaustion that have not been assessed.
Strengths: positive (well-being), includes mental and social health. Criticisms: "complete" is unrealistic, labelling almost everyone unhealthy; it does not fit people living well with chronic conditions (also: cultural differences).
A line from premature death through signs and symptoms to a neutral point, then towards high-level wellness. Treatment moves a person from the illness side to neutral; wellness (awareness, learning, growth) moves the person beyond neutral.
For example, loneliness or conflict at home can cause stress, poor sleep and poor appetite, which raise blood pressure and weaken resistance to infection.
Against: Gasana has a disease but feels well, and Eric has no diagnosed disease but suffers; the WHO includes mental and social well-being; Travis and Antonovsky describe positive health beyond neutral. For: absence of disease is easy to measure and is the basis of medicine. Judgement: it is part of health but far from all of it.

Sources and credits

Constitution of the World Health Organization (adopted 1946, in force 1948); Mental health: strengthening our response, WHO fact sheet (2022).
Works described: Huber, M. and others (2011), "How should we define health?", BMJ 343; Twaddle, A. (1968), Influence and Illness, PhD thesis, Brown University; Kleinman, A. (1988), The Illness Narratives, Basic Books; Travis, J. W. (1972), the illness–wellness continuum, later published in Travis, J. W. and Ryan, R. S., Wellness Workbook (1981); Antonovsky, A. (1979), Health, Stress and Coping, Jossey-Bass.

Written by Ganzaa: the text, the diagram (Figure 1), the table and the exercises.

1Who is healthy?

21. Disease, illness and sickness

32. Evaluating the WHO definition

43. Health as a continuum

54. Dimensions of well-being

Who is healthy?

1. Disease, illness and sickness

2. Evaluating the WHO definition

3. Health as a continuum

4. Dimensions of well-being