Health care needs need to be focused on health

doi:10.4236/health.2011.36064

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Vol.3, No.6, 378-382 (2011)

doi:10.4236/health.2011.36064

Health

Health care needs need to be focused on health

Johannes Bircher1, Karl-Heinz Wehkamp2

1Hepatology, Department of Clinical Research, University of Bern, Bern, Switzerland; [email protected]

2Life Sciences Faculty, HAW Hamburg, Campus Bergedorf, Lohbrügger Kirchstr, Hamburg, Germany; [email protected]

Received 15 April 2011; revised 10 May 2011; accepted 23 May 2011.

ABSTRACT

In the past decades health care and medicine in

most countries got more or less in a state of

crisis. This is not surprising because, so far,

there is no consensus about the nature of

health. This shortcoming inhibits constructive,

interdisciplinary dialogues about health values.

It renders priority setting controversial and

subject to power struggles. A new definition of

health, known as the Meikirch Model, could

correct this deficiency. It states: “Health is a

dynamic state of wellbeing characterized by a

physical, mental and social potential, which

satisfies the demands of a life commensurate

with age, culture, and personal responsibility. If

the potential is insufficient to satisfy these de-

mands the state is disease.” The potential is

composed of a biologically g iven and a person-

ally acquired component. Thus this definition

characterizes health with six essential features,

which are suitable for an analysis of and priority

setting in medical consultations and in health

care policy decisions. A wide discussion about

this definition of health followed by its imple-

mentation is expected to render health care in-

dividually and socially more beneficial.

Keywords: Health; Definition of Health; Health

Care Systems; Health Care Need s ; Meikirch Model

1. INTRODUCTION

In most countries health care systems are now in a

chronic state of crisis. This is due to many reasons, yet a

rapid increase in costs and a change in values appear to

be predominant. Physicians have lost control of health

care in favor of economists and politicians. As a result

leadership is no longer based on medical but on eco-

nomic and political values. In health personnel this has

created much insecurity and frustration.

Currently, the predo minant question is how to redirect

the self-organization of health care systems and how to

integrate them into the resp ective societies. Management

of complexity is a challenge that is well known in large

organizations. Experienced leaders generally focus with

great care on the “product” their organization has to re-

alize. They insist that all persons within their realm of

influence know exactly what the purpose of their or-

ganization is. Yet, when it comes to health care, it is as-

tonishing that the very purpose of the system, i.e.

“health” cannot be described. Everybody speaks with

respect about health, yet no one can explain what it

really is. As a result, in most health care systems, the

level of misunderstanding and conflict is high. This can

be exemplified by the following statement: “Patients are

customers and physicians service providers.” This obvi-

ously is the opinion of economists, yet most physicians

and patients would wholeheartedly disagree. Many such

misunderstandings may be found at all levels of health

care systems. In order to guard against them, a new un-

derstanding about the terms of health and disease must

be created.

In 1946 WHO declared its famous definition of health

[1]. It reads as follows: “Health is a state of complete

physical, mental and social well-being and not merely

the absence of disease or infirmity.” At that time this was

a significant advance because for the first time it offi-

cially postulated the importance of mental and social

factors for health. Since then, however, our understand-

ing of physical condition s, mental functioning and social

wellbeing has markedly evolved. As a result the WHO

definition is now considered to be idealistic to an extent

that almost no one can consider him or herself to be

healthy. Consequently, agreement with this definition

has become limited and, at the present time, it can no

longer serve as a central concept for the implementation

of health care systems. We now need a concept of health

that respects the dignity of each person, distinguishes

between health and disease, provides essential elements

for the process of diagnosis and reimbursement and

clarifies the relationship between individual, and society.

An analysis of different descriptions of health reveals

J. Bircher et al. / Health 3 (2011) 378-382

379379

that most of them have merits and validity from certain

points of view and limitations from others [2]. This may

be explained by the fact that it is difficult to develop

concepts with sufficient interdisciplinary merits. Most

authors know their own fields best and attach less im-

portance to others. The definition, which has become

known as the Meikirch Model, is based on experiences

reflected by physicians [3]. It uses six specific criteria to

describe health, all of which may be surveyed or inves-

tigated when examining human beings or health care.

Consequently, the Meikirch Model appears to be suitable

for application in medicine and in health care systems.

2. DESCRIPTION OF THE MEIKIRCH

MODEL [4,5]

Health is defined as follows: “Health is a dynamic

state of wellbeing characterized by a physical, mental

and social potential, which satisfies the demands of a life

commensurate with age, culture, and personal responsi-

bility. If the potential is insufficient to satisfy these de-

mands the state is disease.” The latter includes sickness,

illness, ill health, and malady.

In this definition the potential consists of two compo-

nents, a biologically given and a personally acquired

potential (Figure 1). At birth the biologically given po-

tential has a finite value. Thereafter it decreases

throughout life and at the time of d eath it is zero. In con-

trast, the personally acquired potential is quite small at

the time of birth, but increases rapidly during childhood

and adolescence. It may rise throughout life, provided an

individual cultivates it. It may be damaged by neglect,

alcohol or dugs, etc. It may also be hurt by social sur-

roundings that are not supportive enough, over demand-

ing, or frankly destructive. Therefore social support for

health is crucial [6].

The demands of life are those that we have to respond

to in order to lead a healthy life. (They must not be con-

fused with demands a person may have toward life.

These have nothing to do with the Meikirch Model.) A

baby and a child are cared for by their social surround-

ings, such as mother, father, siblings, teachers, etc. Dur-

ing their productive years all individuals have to con-

tribute to the society. Pensioned elderly persons are

again supported by the society. Consequently, the de-

mands of life vary continuously with th e age of a p erson.

At the same time the culture of a society modifies these

demands, a factor which needs to be taken into consid-

eration. A final important aspect is personal responsibil-

ity of each individual for his own health.

In each person the decision about health or disease

depends on the balance between the total potential and

the demands of life (Figure 2). If the two partial poten-

tials combined outweigh the demands of life, a person is

healthy. In co ntrast, if they weigh less, the person is dis-

eased.

Within this context it is important to appreciate the

nature of these potentials and why they are essential. At

the time of birth the biologically given potential is the

result of the genetic equipment and of the quality of the

pregnancy. It consists of all biological aspects of life,

which need to be protected, properly cared for and

treated responsibly throughout life. The personally ac-

quired potential is more difficult to understand. It com-

prises not only every capability a p erson has learned, but

also some physical aspects that are acquired while

learning. The capability of forming immune reactions,

e.g., is biologically given, but the immunities we have

are acquired. Obviously, emotional maturity and spiritual

growth are part of the personally acquired potential. Fi-

nally, the way we overcome misadventures, injuries, and

possibly severe harm may support or damage our per-

sonally acquired potential.

A good example to illustrate the contribution of each

potential to the health of an individual is paraplegia re-

sulting from an accident to the spinal cord. Such a con-

dition (until now) represents an irreversible damage to

otential

Tim e

eath

irth

Biologically

gi ve n

personally

acquired

Figure 1. The potential of a person consists of two

components, a biologically given and a personally ac-

quired potential. In the graph the two lines are drawn ar-

bitrarily, yet they show that during a lifetime the contri-

bution of each component to the total potential varies

continuously.

Disease

Healt h

Demands

of life

Combined

potentials

Demands

of life

Combine d

potentials

Figure 2. The decision about health or disease depends

on the balance between the sum of the combined poten-

tials and the demands of life. As with the decision about

day and night the distinction between health and disease

is clear in a majority of cases, but in some instances it

may be blurred.

J. Bircher et al. / Health 3 (2011) 378-382

380

the biologically given potential. Yet, through rehabilita-

tion, which is exclusively concerned with the personally

acquired potential, such persons may again become in-

dependent and even professionally active. It shows that

the personally acquired potential may in p art compensate

for reductions in biologically given potential. This fact

creates hope and supports patients with chronic diseases

because they realize that they can do something about

their condition, even when improvement of their physi-

cal state can no longer be expected. In a similar way the

personally acquired potential gives hope to the elderly.

In order to fully appreciate the Meikirch Model, some

further detai l s need to be u nde rst o od:

1) A relatively large number of healthy persons com-

plain about discomfort and pains [7]. Consequently,

health does not imply a “state of complete physical,

mental and social well-being”, because most healthy

persons regularly hav e some co mplain ts. Yet, they know

how to deal with them. This observation further supports

the idea that health is related to an ability to master the

demands of life.

2) Chronically ill persons or humans with e.g. a

metabolic or an immunological shortcoming may need

long term treatment in order to lead a “healthy” life. For

this reason two states of health must be distinguished,

one without treatment and the other with a long term

therapy, such as in hypothyroidism, diabetes mellitus,

arterial hypertension, rheumatoid arthritis, etc.

3) The term potential may be somewhat elusive to

grasp because it has to do with the future of a person. It

must, however, be realized that medicine and health care

are not so much concerned with the present but with an

improvement of each person's future. The very purpose

of medicine and public health is to preserve or restore

whenever possible the immediate, medium, and long

term future of patients and citizens. For these reasons the

concept of “potential” is more appropriate than e.g.

“condition”.

3. THE IMPORTANCE OF A DEFINITION

OF HEALTH FOR MEDICINE AND

HEALTH CARE

“In any field, improving performance and account-

ability depends on having a shared goal that unites the

interests of all stakeholders. In health care, however,

stakeholders have myriad, often conflicting goals in-

cluding access to services, profitability, high quality, cost

containment, safety, convenience, patient-centeredness,

and satisfaction. Lack of clarity about goals has led to

divergent approaches, gaming of the system and slow

progress in performance improvement.” With this intro-

duction Michael Porter pleads for his concept of values,

which he defines as health outcomes achieved per dollar

spent (Figure 3) [8]. The problem of divergent objec-

tives is well known in business organizations. In fact,

experienced leaders take great care to identify and ex-

plain the purpose of their institution. By communicating

it they intend to reach a higher level of cooperation and

performance. In health care the overriding goal is obvi-

ous. All persons must work for the health of the people.

Therefore it is now of critical importance to urgently

achieve a consensus about what health is and to commu-

nicate it. It is our understanding that at present the

Meikirch Model is the best available response to this

need.

Another independent method to appreciate the impor-

tance of a definition of health may be derived from the

social systems theory [9]. Ta bl e 1 shows some essential

Politicians

Administrations

Nursi ng

Physi cians

Insurance

Companies

Patients

Relative s

Mi nistry o f Hea lth

Lawyers

Spe cialists

Fri ends

Hospitals

Goals

Physiotherap

Figure 3. Lack of a common goal divides stakeholders

in the health care system: As many goals are pursued as

there are persons involved. Presumably this is a central

reason for the different crises and the slow progress of

health care systems.

Table 1. Comparison of some essential features of

medicine and health care with selected examples of

other social systems. Each system responds to demands

by speci fic actions. Whe ther or not an act ion takes place

is governed by the generalized symbolic medium of

communication. In the case of medicine and health care

this medium has no specific meaning, because health

and disease have, up till now, remained undefined.

Therefore, actions within this system occur much more

arbitrarily than in the other social systems. This is dam-

aging.

System DemandsGeneralized

symbolic medium

of communication

Specific

Actions

Economy Goods,

Services Money

($, £, €, CHF) Purchase or

no Purchase

Legal

System Justice System

of laws Agreement,

Court Order

Science New

Knowledge Peer

Review Financing,

Publication

Medicine,

Health CareImproved

Health Health and Disease

(undefined so far) Diagnosis,

Treatment

J. Bircher et al. / Health 3 (2011) 378-382

381381

features of a system. Each of them responds to demands

that induce actions. Whether or not this action occurs is

governed in each specific case by a generalized symbolic

medium of communication. For instance, in an economy,

people demand goods and services. Whether these are

purchased or not depends on money. Only if the price is

adequate for the goods or services, are they bought. In

the legal system there may be a demand for justice,

which can be responded to by an agreement or by a court

order. Both cases must conform to the law in order to be

valid. Therefore, in the legal system, the laws play the

role of the generalized symbolic medium of communica-

tion. In science there is a demand for new knowledge.

For both, the financing of projects and for their publica-

tion in scientific journals peer review is required. These

examples may illustrate two features of a generalized

symbolic medium of communication: It plays a central

role for the processes that occur within the system and

its nature is specific for each system. In medicine and

health care by necessity the concept of health and dis-

ease serves as symbolic medium of communication.

Consequently, it is pivotal for the health care system not

to leave health and disease within the realm of arbitrary

individual judgments, but to define them in such a way

that everyone can agree about them. If in health care

money would serve as generalized symbolic medium of

communication, medicine would become part of the

economy and lose its specific nature.

4. WHY CHOOSE THE MEIKIRCH

MODEL?

When opting for a definition of health, it is important

to compare it with the best possible alternatives. For lack

of space only two eminent examples are discussed here:

1) Christopher Boorse [10] proposed a biostatistical

value-free definition. He explains “health as the absence

of disease” and “disease as a type of internal state, which

is either an impairment of normal functional ability, i.e. a

reduction of one or more functional abilities below typi-

cal efficiency, or a limitation of functional ability caused

by environmental agents”. Normal functional ability is

defined by statistical comparison with an age and sex

specific reference group. The value of this definition of

health and disease consists in the fact that it is based on

measurements and statistics. It has been criticized, how-

ever, on the basis that the selection of a reference group

is not truly value-free, but requires a normative judg-

ment. In addition the definition does not structure the

health problem of p atients. If a statistical significance of

p < 0.05 is chosen, 5% of normal subjects are diseased.

In addition, to define health, it is needed to measure the

appropriate parameter. In practice this is difficult.

2) Lennart Nordenfelt [11] proposes a welfare theory

of health. He considers health to be the primary concept

in the web of medical thinking. He states: “A is com-

pletely healthy if, and on ly if, A is in a bodily and mental

state which is such that A has an ability to realize all his

or her vital goals, given accepted circumstances.” This

ingenious definition is normative and derived from the

action theory. For the purpose of medicine and health

care, though, the terms he uses are difficult to apply in

practice. How do we assess e.g. vital goals or accepted

circumstances?

3) Several other normative definitions use among

other criteria the need or lack of need for medical care as

a decisive factor to define health or disease. This leads to

circular reasoning because disease in turn justifies by

itself the administration of medical care.

The Meikirch Model is also normative. Its practical

importance lies in the fact that all six criteria for the de-

scription of health or disease may be assessed in consul-

tations with patients. Therefore they may serve as crite-

ria to analyze value in health care, i.e. health outcome

per dollar spent [12]. In addition, it structures the com-

ponents of health in such a way, that they may be used in

research, in advising individual patients, in medico legal

expertises and in policy decisions for public health. The

Meikirch Model may also serve to explain the nature of

medicine to members of other social systems, e.g.

economists, managers, politicians, lawyers, and scien-

tists. If they understand the model, it may provide the

common denominator for joint policy decisions [13].

This is particularly pertinent, because health care con-

tinuously evolves together with the other social systems.

If, as postulated by Porter [12], the measurement of

value must be its fundamental goal an d improving value

the driving force for every participant, the Meikirch

Model could become a pivotal reference point for this

purpose.

As a next step the different stakeholders need to be

able to perceive the usefulness of the Meikirch Model

and to agree to apply it for interdisciplinary communica-

tion about health care. For this purpose it probably is

useful to start with a widespread discussion on this sub-

ject. More details may be found on a website [5]. Once

the Meikirch Model corresponds to a general under-

standing, it is expected that medicine and health care

will tangibly be more beneficial socially.

5. CONFLICT OF INTEREST

STATEMENT

There are no funds involved from any side. For both authors there

are no conflicts of interest.

REFERENCES

[1] Grad, F.P. (2002) Preamble of the constitution of the

J. Bircher et al. / Health 3 (2011) 378-382

382

World Health Organization. Bulletin of the World Health

Organization, 80

doi: 10.1590/S0042-96862002001200014

[2] Franke, A. (2006) Modelle von Gesundheit und Krank-

heit. Hans Huber Hogrefe AG, Bern.

[3] Bircher, J. and Wehkamp, K.-H. (2006) Das ungenutzte

Potential der Medizin. Rueffer and Rub Publ, Zürich,

44-77.

[4] Bircher, J. (2005) Towards a dynamic definition of health

and disease. Medicine, Healthcare & Philosophy , 8, 335-

341.

doi:10.1007/s11019-005-0538-y

[5] Bircher J. and Wehkamp K.H. (2011) Gesundheit und

Medizin. 10 Thesen—Wie kann ein Gesundheitswesen

funktionieren, wenn niemand sagen kann, was Gesund-

heit ist? Monsenstein und Vannerdat Verlag, Münster,

Germany.

[6] Marmot M. and Wilkinson, R.G. (1999) Social deter-

mineants of health. Oxford University Press, Oxford.

[7] Lieberherr, R., Marquis, J.F., Storni, M. and Wieden-

mayer, G. (2007) Gesundheit und Gesundheitsverhalten

in der Schweiz 2007. Schweizerische Gesundheitsbe-

fragung, Neuchâtel, Switzerland, Bundesamt für Statistik.

[8] Porter, M.E. (2010) What is value in health care? The

New England Journal of Medicine, 363, 2477-2481.

doi:10.1056/NEJMp1011024

[9] Chenilo, D. (2002) The theorization of social co-ordin-

ations in differentiated societies: The theory of general-

ized symbolic media in Parsons, Luhmann and Habermas.

British Journal of Soc io l og y, 53, 431-49.

doi:10.1080/0007131022000000581

[10] Boorse, C.A. (1997) Rebuttal on health. In: Humber J.M.

and Almeder R.F. Ed., What is disease, Humana Press,

Totowa NJ, 1-134.

[11] Nordenfelt, L. (2001) Health, science and ordinary lan-

guage. Editions Rodopi BV, Rodopi, New York.

[12] Porter, M.E. (2008) Defining and introducing value in

health care. In: McClellan M.B. Ed., Evidence-Based

Medicine and the Changing Nature of Healthcare: Meet-

ing Summary, National Ac a demies Press, IOM, 161-72.

[13] Savigny, de D. and Adam, T. Ed. (2010) Systems think-

ing for health care strengthening. Advances in bioinfor-

matics, 2, p. 268925.