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The word "health" derives from Middle English helthe, meaning hale, hearty, sound in wind and limb. Dictionary definitions allude to soundness and efficient functioning and give the same meaning to financial health as to bodily health. Modern medical practice and public health are concerned about the health of individuals and populations. However, for most individuals and for many cultures, health is a philosophical and subjective concept, associated with contentment and often taken for granted when all is going well. Health in this sense is difficult to describe or define, but its absence is readily recognizable, even when replaced by minor departures from an accustomed level of health.


In the preamble to the constitution of the World Health Organization (WHO) health is described as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." This description has often been criticized as being too vague. Further, it describes an ideal state rarely attained by most people, and it contains no ingredients that can be readily measured or counted, either at the individual or the population level.

Another definition, composed by specialists in preventive medicine, specifies some tangible components of health; calling it "a state characterized by anatomical, physiological, and psychological integrity; ability to perform personally valued family, work, and community roles; ability to deal with physical, biological, psychological, and social stress; a feeling of well-being; and freedom from the risk of disease and untimely death" (Stokes, Noren, and Shindell, 1982). Everything mentioned in this definition can be measured and counted at the individual and at the population level, although assessing "a feeling of well-being" may be a challenge, and "freedom from the risk of disease and untimely death" is not an achievable state.

An increasing level of interest in health promotion in the early 1980s inspired a WHO working group to compose a definition recognizing the role of individuals and communities in determining their own health status. They can be paraphrased to the extent to which an individual or a 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 capabilities (Last, ed., 2000). This definition draws attention to the need for partnerships among individuals and communities, and to the importance of protecting the integrity of the environment in the cause of promoting good health. Moreover, many aspects of this definition are measurable.

The health of humans cannot be dissociated from the health of the life-supporting ecosystems with which humans interact and are interdependent. Moreover, no matter how healthy the present generation may be, the health of future generations is dependent upon the integrity and sustainability of these ecosystems. A definition of "sustainable health" that recognizes this interconnectedness states that health is a sustainable state of equilibrium among humans and other living things that share the earth (Last, ed., 2000). The key word in this definition is "equilibrium" meaning harmony. Human beings cannot long remain healthy in an environment in which they are out of harmony with other living things, or if other living things are dead or dying as a consequence of people's actions. This is true of all life forms, from the smallest microorganisms to the largest mammals. Since the midtwentieth century, medical professionals have been trying to "conquer" pathogenic microorganisms with antibiotics. This is a war that ultimately cannot be won because micro-organisms have very short generation times, measurable in minutes. Microorganisms can therefore adapt to the challenge of antibiotics by evolving and producing antibiotic-resistant strains much more rapidly than new antibiotics can be developed.

An alternative to antibiotics, which is perhaps insufficiently implemented, is based on the ecological concept that humans are an integral part of the global ecosystem. Immunization programs aimed at protecting people from diphtheria, tetanus, and other diseases have been very effective. The microorganisms responsible for these diseases are still there, in people's throats, in the soil, wherever is their usual habitat. But once protected by immunization, people can live in harmony with these otherwise dangerous microbes. The challenge is to develop methods that will enable humans to live in harmony with other dangerous microorganisms and insect vectors of disease. This is a more certain way to ensure long-term health for the population than the impossible goal of attempting to exterminate these other life forms. Pathogens that have no other host than humans can sometimes be eradicated, as the smallpox virus was, and as the polio virus could soon be, at least regionally if not globally; but eradication is not feasible with microorganisms that can survive out-side human hosts.


Beliefs about the foundations of good health are inseparable from theories of disease. Primitive beliefs about good and evil spirits; the benevolent or malevolent intervention of fate, gods, or ancestors; disease as a punishment for sin (Murdock, 1980); theories such as those of Aristotle and Galen about the balance of bodily fluids (humors) and about the effects of miasmas or "bad air" survive in the names by which we know some common diseases, including influenza, malaria, cholera, and rheumatism. A preference for holiday resorts and convalescent hospitals at the seaside or in the mountains reflects a belief in the notion that some environments are inherently healthier than othersas, indeed, abundant evidence demonstrates.

Scientists can trace the evolution of medical science in the changing nomenclature of disease. Some modern diagnostic labels indicate a precise understanding of the causal mechanisms of diseasestreptococal septicemia is, literally, the poisoning of the blood by streptococcus bacteria. Some that sound impressive, such as thrombocytopenic purpura (bruising associated with a deficiency of thrombocytes, or blood platelets) reveal partial knowledge: scientists know what causes the bleeding but not what causes the deficiency of platelets. Other disease names are deservedly vagueessential hypertension confesses out ignorance about what actually causes high blood pressure.

Modern medicine and public health embrace several theories that are confirmed by abundant empirical and experimental evidence, and medical professionals have an increasingly broad and deep understanding of the ways in which health of individuals and populations can be impaired, endangered, of permanently lost. Scientists know that many diseases are caused by invading pathogenic microorganisms, which are often communicable. Some diseases are due to a disruption or imbalance among endocrine glands that secrete hormones needed to ensure efficient bodily function, some are caused by dietary deficiency of essential vitamins or minerals, and others are caused by exposure to harmful chemicals or physical insults such as ionizing radiation or excessive noise. Some diseases are due to, or strongly associated with, emotional stress. There remains a residue of important, and sometimes common, diseases and causes of disability and premature death for which there is no known cause, although effective treatments have been developed for some of theses, often through trial and error or guesswork. High blood pressure is one such disease.

The activities of public health services aim to minimize the risk of serious departures from good health. The scope and methods of medical and public health practice demonstrate the depth and breadth of current understanding of the causes of disease, disability, and premature death, and also of the causes of good health.

Many who remain fit throughout a long lifetime attribute their good health (often incorrectly) to their behavior; whether it be to an ascetic or hedonistic way of life, to abstaining from (or indulging in) alcohol or tobacco, to vigorous exercise, or to leading a quiet, sedentary life. Some credit their parents or genetic heritagecertainly an important determinant of longevityalong with many environmental and behavioral factors. In fact, the causes of good health are as diverse and complex as the causes of disease.

Even literate, well-educated people sometimes have misguided views about what makes or keeps them healthy, often believing that regular daily exercise, regular bowel movements, or a specific dietary regime will alone suffice to preserve their good health. The Nobel laureate Linus Pauling believed that massive daily doses of Vitamin C preserved his health. Those who are less well educated and more gullible are easy prey to hucksters who purvey all manner of dubious nostrums to prolong life, enhance vitality or virility, promote fitness, and eliminate ailments ranging from halitosis and body odor to failing sexual potency and even cancer and heart disease.

Modern approaches to health education and health promotion make use of the Health Belief Model along with several other theoretical constructs to predict health-related behavior. These are based on assumptions derived from empirical studies of how people perceive their health and their understanding of what has to be done to preserve and protect their own health, or that of their children.


A well-trained physician, or an observant member of a family, can often tell at a glance that someone is unwell. There are obvious signspallor, sweating, unsteady gait, a bone-shaking cough. The converse is more challenging. Someone who appears to be outwardly perfectly fithale and hearty, sound in wind and limbmay harbor an early cancer that is eating away at a vital organ, or, when asked the right questions may reveal a potential mental health problem, though there is no physical evidence of a departure from excellent health. Health has many dimensions, and each must be assessed and measured on some sort of scale. This is what physicians do when conducting a routine medical history and physical examination, which includes various laboratory tests. The results of such an examination have a range of values that usually follow a normal distribution, and for many of these the decision that a particular value lies within or outside the range of normal is rather arbitrary, although it is based on empirical experience. For example, experience and follow-up of many sets of observations allow us to agree on what level of systolic and diastolic blood pressure give grounds for a confident recommendation that treatment is needed to reduce an excessively high pressure that could lead to a stroke or heart attack.

Conversely, many severely disabled people can function efficiently and cheerfully within their limited capacityparaplegics can perform with consummate speed and skill in road races in wheelchairs, and blind people can play chess and swim in competitive tournaments. The theoretical physicist Stephen Hawking, described in his book, A Brief History of Time (1988), the full and productive life he leads, though he is profoundly disabled physically by amyotrophic lateral sclerosis (Lou Gehrig's disease). Physical, mental, and emotional health are clearly three different dimensions of health.

Determinants of Health. Both individual and population health are determined by physical, biological, behavioral, social, and cultural factors. First among the physical factors is the radiant energy of the sun, which is ultimately essential for all life on earth. In Airs, Waters, and Places, Hippocrates identified climate, environmental topography, and aspects of behavior as determinants of health. Climate is assuming greater importance than hitherto due to the climate changes caused by increasing industrialization and energy consumption. Environmentally, the presence or absence of trace elements in the soil or water, such as fluorides to toughen dental enamel, iodine to stimulate the thyroid gland, and lead compounds that damage the developing brain, act to enhance or impair our health.

Biological determinants of health are inherent or acquired. Genetic heritage is a contributing factor to longevity, and to susceptibility or resistance to a wide range of diseases that include the pathogenic microorganisms responsible for some of the great plagues that have afflicted humans for millennia. Molecular geneticists have demonstrated that the interaction of human communities with the plague bacillus, the influenza and smallpox viruses, the malaria parasite, and with several other microorganisms, played a role in determining the differentiation and distribution of early races of humans in Africa and Asia. On a much shorter time scale, pathogenic microorganisms may be the most important biological determinants of health and disease. Immunity or resistance to pathogens is a very important determinant of good health. Immunity is enhanced by prior exposure, or by maternal exposure in the case of newborn infants, who acquire maternal (passive) immunity to some infections before they are born, and have it reinforced after birth by antibodies in breast milk. Routine immunization of infants and small children protects them from harm by many common and formerly dangerous pathogens including those that cause diphtheria, tetanus, measles, poliomyelitis, and whooping cough. Nutritional status is another important influence on resistance to infection. Individuals and populations are most vulnerable when they are malnourished or starved, which is why plagues often accompany famines.

Behavioral determinants have been much studied. An association of certain diseases with particular personality types has been observed empirically for centuries. An irascible temperament, for example, has been linked to occurrence of strokes, and an association has been demonstrated between high risk of coronary heart disease and a type A personality, marked by forceful and aggressive behavior. Research on mind-body interactions, which unites the disciplines of psychology, neurology, and immunology, made great progress in the last quarter of the twentieth century and began to clarify and explain these relationships.

Social factors that influence or determine health are also complex. There is epidemiologic evidence that good health is determined at least in part by social connectedness. Persons who have many and frequent interactions with other family members and with a network of friends have a more favorable health experience in many ways than those who are socially isolated, live alone, are estranged from their family, and have little or no family and social support systems. It is difficult however, to unravel social connectedness and personality factors that may encourage gregariousness or a solitary way of life. Position in the social hierarchy plays a role. Michael Marmot, a professor at University College in London, and his colleagues studied British civil servants, showing that top managers lead healthier lives than middle managers, who in turn are healthier than semi-skilled and unskilled clerical workers. Social networks and support systems, and social positions, are in part determined by factors beyond the control of individuals. While they are interrelated with personality factors, they are very complex and not well understood.

Studies have shown that economic conditions dramatically effect health and longevity. A consistently strong relationship has been demonstrated between income levels and health status in every country where the relationship has been examined. Many interactions between social, economic, and cultural factors also help to determine or influence community health.

Culture is defined as the set of customs, traditions, values, intellectual, and artistic qualities, and religious beliefs that distinguish one social group or nation from another. Culture influences behavior through customs such as use of or abstention from meat, alcohol, and tobacco; the practice of rituals such as circumcision; marital customs such as the prevailing age at which women marry; attitudes toward family size, childbearing, and child rearing; personal hygiene; disposal of the dead; and much else. People's values may be the most significant component of culture that affects behavior and through behavior, health. For example, since the late nineteenth century, an understanding of the importance of personal hygiene has become part of the value system of many cultures. In the late twentieth century, values in many nations shifted towards a rejection of tobacco smoking as a socially acceptable custom. In the 1960s, the oral contraceptive pill contributed to the sexually liberated values and behavior that encouraged casual promiscuity, and which was only partially overshadowed by the threat of infection with HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) in the 1980s and later.


Another way to consider conditions required for people's health to flourish was outlined by working groups of the World Health Organization Regional Office for Europe in the 1980s, during the development of targets to be met in order to achieve Health for All, a program conceived with the goal of assuring that essential health care is accessible to everyone through organized programs of health promotion. The prerequisites for health were identified as: freedom from the fear of war, equal opportunity for all, satisfaction of basic needs (food, education, clean water and sanitation, decent housing), secure work, a useful social role, and political will and public support. All these are embodied in one way or another in the determinants of health outlined above, but when expressed as they were by the WHO working groups, the relevance of human values to achievement of good health becomes more explicit. Ultimately, values may matter more than anything else in influencing health.


The basic goals of health promotion and health maintenance are a safe environment, enhanced immunity, sensible behavior, good nutrition, well-born children, and prudent health care. Each of these merits a brief discussion.

Safe Environment. Among the fundamental requirements for good health are clean air, safe water, land free from toxic substances, and shelter that protects people against the elements. The term "filth diseases" coined in the midnineteenth century, summarizes many life-shortening environmental hazards that prevailed at that time. Unpolluted water, sanitary disposal of human wastes, and improved housing conditions transformed overall health by the end of the nineteenth century. Access to food and resources essential for survival, as well as freedom from threat of war, persecution, and discrimination, are included in the European Charter for Health Promotion. A high proportion of the world's people are in want of these essential requirements for good health.

Enhanced Immunity. Next in importance to the provision of pure water supplies and sanitary disposal of human waste is the protection of infants and children against lethal and crippling infectious diseases. By the middle of the twentieth century, immunization campaigns had virtually wiped out diphtheria, tetanus, and whooping cough. Smallpox was eradicated worldwide by 1980. Development in virus vaccines in the second half of the twentieth century added poliomyelitis, measles, rubella, and mumps, to the list of diseases preventable through vaccination. This list includes other dangerous diseases that are rare in Western industrial nations, including typhoid, typhus, and yellow fever.

Sensible Behavior. The way people behave influences their health in many ways, and behaving sensibly is an obvious requirement for good health. Health-related behavior is influenced by our values, which are determined by upbringing, by example, by experience, by the company one keeps, by the persuasive power of advertising (often a force of behavior that can harm health), and by effective health education. These influences affect everyoneespecially impressionable childrenand lead to good or poor health, depending on the predominance of sensible or risk-taking behaviors that result.

Good Nutrition. A balanced diet comprises a mixture of the main varieties of nutriments (protein, carbohydrates, fats, minerals, and vitamins). For many reasons, not everyone has easy access to or incentives to eat a balanced diet. Some cannot afford it, others are ignorant of what kinds of food are good for them and what kinds are not; many are attracted by the advertising, convenience, and low cost of junk foods. Nevertheless, those who eat a well-balanced diet are healthier than those who do not.

Well-Born Children. By this term we mean children who are free from genetic defects, safely and easily born to healthy mothers after a pregnancy of normal duration, and nurtured securely to ensure that they pass developmental milestones in a timely manner so they grow up fit and strong. A great many characteristics are summarized in that statement, and are discussed elsewhere in this encyclopedia.

Prudent Health Care. It has been said that, until about 1930, the average patient with the average disease consulting the average physician had a less than 50 percent chance of benefiting from the encounter. In some respects the situation has greatly improved since then, but doctors even now inadvertently harm some whom they attempt to help, and hospitals remain dangerous places where patients are at risk of infection by other patients and contaminated instruments, invasive procedures can go wrong, and medications can be administered to the wrong patient or given in wrong dosages.


The health of potential military recruits and applicants for life insurance is assessed by their past history of illness and harmful behavior (e.g., smoking), and by a physical examination that includes blood pressure, tests of exercise tolerance, and other measures. Similar methods can be used to assess the health of a nation. The physical examinations of military conscripts early in the twentieth century provided evidence of the poor health of the British working classes, and which in turn motivated the government to introduce the first tax-supported medical services. In the United States, the National Health Surveys provide information about the health status of Americans (such as the increasingly prevalent obesity among young people). But this is a costly way to assess a nation's health. Traditionally, health care professionals have relied on summary statistics, especially life expectancy, which is derived from the age distribution of the population as determined by a national census. Life expectancy at birth is particularly sensitive to infant mortality, which is another widely used indicator of a nation's level of health.

More sensitive indicators take into account the available evidence on commonly occurring disabling diseases to derive summary statistics such as disability-adjusted life years. Health measurement scales are more elaborate derivatives of disability-based health indicators. These require the use of questionnaires, interviews, and sometimes physical examination of individuals to derive a numerical score for particular aspects of health such as an ability to climb stairs, shop for food, prepare meals, get dressed unaided, or drive a car. Standardized interviews can also be used to derive a numerical score for aspects of mental health, social interaction with others, and employability. When all available health indicators are complied, various conclusions can be drawn. They show, for example, that Japan, Australia, Sweden, the Netherlands, and Canada are among the world's healthiest nations; while Sierra Leone, Mozambique, and Malawi are in many respects the least healthy. The United States is among the top twenty nations according to some indicators, and among the top twenty-five according to others. But no nation has a monopoly on indicators of good health. If athletic prowess is an indicator, African Americans consistently outperform all others in sprints, while Africans from Kenya outperform all others in middle- and long-distance running. Some small nations in the mountainous Caucasus region between the Caspian Sea and the Black Sea, in the

Table 1

The top 25 and the bottom 25 nations ranked according to Disability-Adjusted Life Expectancy (DALE)
Rank Nation DALE Rank Nation DALE
source: World Health Organization, 2000.
1 Japan 74.4 166 Djibouti 37.9
2 Australia 73.2 167 Guinea 37.8
3 France 73.1 168 Afghanistan 37.7
4 Sweden 73.0 169 Eritrea 37.7
5 Spain 72.8 170 Guinea-Bissau 37.2
6 Italy 72.7 171 Lesotho 36.9
7 Greece 72.5 172 Madagascar 36.6
8 Switzerland 72.5 173 Somalia 36.4
9 Monaco 72.4 174 Congo 36.3
10 Andorra 72.3 175 Central African Republic 36.0
11 San Marino 72.3 176 Tanzania 36.0
12 Canada 72.0 177 Namibia 35.6
13 Netherlands 72.0 178 Burkina Fasso 35.5
14 Britain 71.7 179 Burundi 34.6
15 Norway 71.7 180 Mozambique 34.4
16 Belgium 71.6 181 Liberia 34.0
17 Austria 71.6 182 Ethiopia 33.5
18 Luxembourg 71.1 183 Mali 33.1
19 Iceland 70.8 184 Zimbabwe 32.9
20 Finland 70.5 185 Rwanda 32.8
21 Malta 70.5 186 Uganda 32.7
22 Germany 70.4 187 Botswana 32.3
23 Israel 70.4 188 Zambia 30.3
24 United States 70.0 189 Malawi 29.4
25 Cyprus 69.8 190 Niger 29.1
191 Sierra Leone 25.9

foothills of Mount Ararat, are famous for many authenticated cases of extreme longevity, and they may have the world's highest proportion of persons surviving to ages over one hundred. Yet these same nations have relatively high infant and childhood mortality rates, as well as high death rates from causes associated with violence.

Determining which nations are healthy depends on which health indicators are looked at. The Netherlands, for example, ranks at the top using indicators of health qualityliteracy levels, low incidence of abortion and unwanted pregnancy, low incidence rates of impairments, disabilities, and handicapsthough other countries may rank higher in terms of longevity and other indicators.

Table 1 shows the ranking of various nations based on years of healthy life expectancy or disability-adjusted life years, the age to which on average people are expected to live in good health. This number is reached by subtracting the average years of ill health from the overall life expectancy. The top nations are Japan, Australia, and France; the bottom three are Malawi, Niger, and Sierra Leone. The United States is twenty-fourth on this list, though it is the richest nation on earth in terms of economic indicators. The poorest fifth of residents in the United States have a healthy life expectancy of just fifty-five years, compared to seventy years for the nation as a whole. Clearly there is room for considerable improvement.


Health is clearly a complex, multidimensional concept. Personal or individual health is largely subjective. It is possible to be physically robust, to be "the picture of good health," and yet have serious mental or emotional impairment. Conversely, an individual can be profoundly disabled physically yet have an intact mind and be emotionally well-adjusted. So while many facets of health can be identified, the assessment or measurement of individual health must take them all into account. Economists can derive a single numberthe net worth or gross domestic productas a measure of the economic status of an individual or a nation. But there is no comparable one-dimensional measurement scale for the health of an individual, much less a nation. At best, public health professionals can create community or national profiles using crude health indicators like life expectancy; infant mortality rates; death or sickness rates from specific causes like cancer, heart disease, suicide, and homicide; or surrogate measurements such as use of drugs, (prescribed or over-the-counter) and spells of hospital care.

Health is, ultimately, poorly defined and difficult to measure, despite impressive efforts by epidemiologists, vital statisticians, social scientists, and political economists. The dramatic differences in levels of health among the nations of the world only challenge public health professionals to pursue global health standards.

At the beginning of the twenty-first century the principal causes of premature death and departures from good health were violence, including violent armed conflict; smoking-related disease; automobile accidents; and overindulgence in high-calorie foods that are ill-suited to modern, sedentary lifestyles. All of these are ultimately associated with human behavior, which is greatly determined by values. Only by adopting values that support a healthy lifestyle can people improve their overall health.

John M. Last

(see also: Assessment of Health Status; Attitudes; Behavioral Determinants; Climate Change and Human Health; Community Health; Cultural Factors; Environmental Determinants of Health; Genetics and Health; Health Belief Model; Health Maintenance; Health Measurement Scales; Health Promotion and Education; Infant Mortality Rate; Lay Concepts of Health and Illness; Life Expectancy and Life Tables; Maternal and Child Health; Mental Health; Nutrition; Social Determinants; Sustainable Health; and articles on specified diseases mentioned herein )


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Dubos, R. (1959). Mirage of Health. London: Allen and Unwin.

Helman, C. (1990). Culture, Health, and Illness, 2nd edition. Oxford: Butterworth-Heinemann.

King, M. (1990). "Health Is a Sustainable State." Lancet 336:664667.

Last, J. M. (1997). Public Health and Human Ecology, 2nd edition. Stamford, CT: Appleton and Lange.

Last, J. M., ed. (2000). Dictionary of Epidemiology, 4th edition. New York: Oxford University Press.

Marmot, M., and Wilkinson, R. G., eds. (1999). Determinants of Health. Oxford: Oxford University Press.

Murdock, G. P. (1980). Theories of Illness. Pittsburgh, PA: Pittsburgh University Press.

Stokes, J. III; Noren, J. J.; and Shindell, S. (1982). "Definitions of Terms and Concepts Applicable to Clinical Preventive Medicine." Journal of Community Health 8:3341.

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Disease and its causes

Three conceptions of health

Modern medical practice

Health beyond the individual


“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” according to the World Health Organization (1946). It will be the purpose of this article to develop some concepts about health and disease, exploring a few implications of the WHO definition in the context of both Western and non-Western medical ideas. First, notions of singular and multiple causation of disease will be contrasted. Second, three types of ideas about health will be defined. Finally, some applications of the health concept to units beyond the human individual will be mentioned.

Disease and its causes

Illness is a disvalued process that impairs the functioning or appearance of a human person and may ultimately lead to death. The definition of health given by the WHO includes social as well as physical and mental well-being. This reflects a concern with the person as a member of human groups—an entity certainly not limited to the body of that person. The components of an individual (e.g., blood, body, soul, spirit, shadow, name, etc.) are defined differently from one culture to the next. The death of the organism, however, is a biological constant which is taken into account conceptually in all cultures, and customs prescribe how the disposition of the corpse is to be arranged. Different components of the individual may be thought to depart from the presence of the living at different times, and these various departures are marked by a series of ceremonies (van Gennep [1909] 1960, pp. 146 ff.). Some components, such as the “soul,” may be thought never to cease existing entirely but to remain near the living or in some locality specially set aside for its kind.

Disease, then, may involve a temporary or permanent impairment in the functioning of any single component, or of the relationship between components making up the individual. An impairment of a person, furthermore, need not be re stricted to a decrease in his ability to function in his ordinary ways: for example, among the Ashanti of West Africa, a congenital birthmark which leads to no discomfort or danger of death can be considered a sufficiently severe fault to disqualify a man from the office of chief. In many cultures, theories of disease will include explanations of congenital defects or imperfections, and the distinction between these and other illnesses may become relevant for further analysis (Polgar 1963).

Explanations of illness are not only useful to reaffirm the values of a social unit or to make death psychologically more tolerable for the next of kin but serve most immediately to indicate courses of preventive and curative action. To effect prevention or cure one should identify a course of events which presumably has produced the impairment. Herein lies the rationale of diagnosis, which is one of the three basic elements of all medical systems (the other two being therapy and prophylaxis).

Notions of singular causation

During the last decades of the nineteenth and the early part of the twentieth century, Western medicine was heavily dominated by the notion that most diseases are a result of infection caused by microorganisms. This type of conception—that disease simply results from the entry by a foreign agency into the body of the patient—is paralleled by the ideas found among many tribal people that illness is caused by “object intrusion” or “spirit possession.” Walther Riese has drawn attention to this similarity of ideas in stating that “ontologic” etiology (a conception of disease as caused by a monadic “alien-ferment”) “in its crudest form …identifies these agents, if not the diseases themselves, with demons, in its scientific form, with germs” (Riese 1953, pp. 66-67). He does not imply, of course, that demons and germs are equally valid concepts in an empirical sense.

The emergence of the “doctrine of specific etiology of disease” (Dubos [1959] 1961, p. 90) as the dominant idea in medicine is related to the mechanistic world view prevalent in the late nineteenth century. Far older features of Western thought, such as the grammatical dualism of subject and predicate, the Judeo-Christian and Platonic mind-body dichotomy, and the experimental approach of the alchemists, provided a suitable background for the development of this “doctrine.” Of the greatest immediate relevance to it were the discoveries of Pasteur and Koch in the realm of bacteriology. Instead of emphasizing the patient and his total environment, as Western medical traditions had done previously, proponents of this “doctrine” spread the notion that all important infections could be controlled by therapeutic serums and preventive vaccines specific for all microbes (Dubos [1959] 1961, p. 130). Although a number of vaccines and antitoxins had been developed before the turn of the century, it was not until the 1930s that the sulfa drugs were discovered, and it was another decade later that penicillin came to be used. The great decreases in the mortality of children and young adults, which are nowadays often attributed to clinical medicine and the use of specific drugs, actually preceded these discoveries and mostly resulted from better nutrition and the hygienic measures carried out under the leadership of medical reformers, many of whom had even opposed the germ theory of disease (Rosen 1958, pp. 225 ff.; Dubos [1959] 1961, p. 131).

In the contemporary practice of clinical medi cine, the inadequate care often received by patients unfortunate enough to suffer from a disability for which no specific etiology can be identified is symptomatic of the legacy of the bacteriological era. Von Mering and Earley (1965) trace the difficulties of such problem patients to, among other factors, the hospital as the main locale for diagnosis and treatment, as well as to the “growth of medicine as a science of tests and measurements rather than an art involving the five senses.” These authors find that “the clinic physician and general practitioner share a kind of ’molecular man’ orientation which seems to predispose them to be more concerned with the specifics of the presenting complaint, and to look eagerly for major disease in every bed or consulting room” (von Mering & Earley 1965, p. 199; see also Pflanz 1964).

Multicausal conceptions of disease

The recent theoretical developments away from the doctrine of specific etiology are spearheaded by advocates of comprehensive medical care and psychosomatic medicine and by some epidemiologists. All three of these segments of the medical community regard illness as an interaction of many factors and, cor respondingly, favor treatment of patients once more as total organisms in a complex setting. One of the foremost modern exponents of this view is the epidemiologist John Gordon, who has shown the interplay of the host, the agent, and the (physi cal, biological, and social) environment in the spread of a good number of both infectious and noninfectious diseases (see, for example, Gordon 1958). The studies of John Cassel, another noted epidemiologist, on the spectrum of health disorders resulting from independently documented socio-cultural processes exemplify a further step away from the one cause-one disease manner of thinking (Cassel 1964). Although writers in the psycho somatic tradition of medicine often use concepts like “stress” or “conflict” as if they were specific causes of illness, the emphasis in this school of thought is on the patient’s physical and mental well-being, and consideration is often given to his social milieu as well (King 1963). Comprehensive medical care is more than a movement to improve the institutional means by which patients and sometimes families are medically supervised. The theory that underlies these arrangements includes rejection of both the dominant disease orientation of modern Western medicine and the organic-functional dichotomy, and it places a strong em phasis on the patient as a person (Steiger et al. 1962).

Multicausal conceptions of disease are neither new in the Western medical tradition nor unique to it. One main theme in the Hippocratic writings is that disease is to be traced to an imbalance be tween the person and his external environment; much emphasis is also given to the relationships among different environmental factors, such as exercise and diet, and to the connections between disturbances in an organ and the whole body (Sigerist 1951-1961, vol. 2, pp. 317 ff.; Dubos [1959] 1961, pp. 117 ff.). In non-Western socie ties there are many multicausal ideas about disease. The distinction between conditions that make persons particularly susceptible and events that precipitate the onset of the disease is particularly common: for example, the Maori of New Zealand see “bad acts” by the patient as predisposing to, and external spirits or objects as the immediate cause of, an illness episode (Newell 1957); in the Middle East, a well-formed male child is identified as especially susceptible to attack by the “evil eye” (Shiloh 1958).

Related to this division between predisposing and precipitating factors is the division between the reasons why a particular person becomes ill at a particular time and the explanation of the way in which it happens. These latter two types of causes may be termed incidence notions and etiological notions (Polgar 1962, pp. 166 ff.); they also bear some similarity to the Aristotelian efficient and material causes (Riese 1953, pp. 66 ff.). In some non-Western medical systems there are categories for “natural” diseases—usually minor ills such as the digestive problems of infants (Nurge 1958)— which do not require an explanation for the occur rence of the disability in the particular instance and hence do not raise questions about who is “re sponsible.” In urbanized as well as nonurban societies, however, the search for the transgression of the patient himself or the malevolent action of another being (human or supernatural) is a major element of the diagnostic process.

In small tribal or peasant communities, the as signment of responsibility for illness to a relative or neighbor (whose departure from prescribed norms of behavior is pinpointed as a breach of taboo, witchcraft, irresponsibility, or sin) helps to bring latent interpersonal conflicts into the open where they are more easily resolved (Paul 1953; Firth 1959, pp. 135 ff.). Similarly in the Judeo-Christian tradition the attribution of illness to sin ful behavior served to reinforce the mores of the society. With increasing secularization, this diag nostic category became less satisfactory, and in scientific medicine it was replaced by “naturalistic” explanations. However, residues of this earlier concept of sin still affect attitudes toward disease; for patients and their families, a physician’s diagnosis which fails to blame anyone for the occurrence of the illness also fails to deal with the sense of guilt they often have and leaves them vaguely dissatisfied (Sigerist 1951-1961, vol. 1, p. 157).

Three conceptions of health

If disease is seen as an individual’s departure from perfectly well-meshed social or physiological performance, health, by contrast, becomes an asymptote—an ideal that can be approached but never attained in actuality. In the WHO definition, the expression “complete physical, mental and social well-being” [emphasis added] echoes this type of conception.

Variants of the asymptotic concept

Two main variants of the asymptotic notion about health can be identified. One variant, the harmonious working together of disparate elements, is a dominant theme in the Indo-European tradition, antedating Galen’s notion of the “four fluids” and manifest today in the influence of Walter B. Cannon’s ideas about homeostasis. The yang and yin of Chinese philosophy also indicate a search for balance, the restoration of which is one of the healer’s primary goals (Huard & Wong 1959, pp. 105 ff.). Grand designs of physiological, physical, and metaphysical order —each replicating the elements of the other—are typical of classical times.

The second type of asymptotic conception is a backward-looking romanticism, which has been described by Dubos in his chapter “The Gardens of Eden” ([1959] 1961, pp. 1-25). For Rousseau and his followers, the ills that beset Western society are consequences of the departure from a perfect state of harmony with nature that is entailed in the process of becoming civilized. Freud also accepted the myth of a precursor of modern man who was exempt from the latter’s neuroses, since this imaginary “savage” did not inhibit the biological drives toward aggression and sexuality (Riese 1953, pp. 14 ff.). Remnants of ideas about “primitive man’s” closeness to “nature” remain today in such medical folklore as the myth of easier parturition among American Indians and the “innate” superiority of their sense organs. When this theme is transposed to the life cycle of individuals, children may be seen romantically (for example, by the poet Wordsworth) as endowed with sensitive understanding which they gradually lose by exposure to the eroding influence of the “civilized” ways of adults.

In operational terms, the asymptotic definition of health is mostly negative; it implies the absenceof manifest disturbance. While this notion has advantages in focusing attention on the nonexistence of a clear break between the presence or absence of disease, by the same token it makes for difficulties in conducting health surveys and planning for medical facilities (Lewis 1953; U.S. Department of Health …1966).

The elastic concept

Another set of notions about health centers on the accumulation of resistance to potential danger. This may be termed the elastic concept. Examples of health behavior derived from this manner of thinking include restricting the water intake of children to make them hardy, homeopathic medicine, and variolation (of differing empirical value, of course). Adversity is not regarded here as a disruption of some prior or ultimate harmony but rather as an ordinary and expected circumstance for which preparations can and should be made. This manner of regarding health seems to play a substantial part in modern preventive medicine. Another good contemporary example of an application of the elastic view of health is psychoprophylactic training for childbirth, by which women are taught to cope with the hardships of delivery through psychological conditioning together with certain exercises (Bing et al. 1961). Some accumulated resistance potentials can be measured operationally in the scientific laboratory by testing an individual’s capacity to produce specific antibodies when challenged by an antigenic substance or his capacity for continued adequate performance of sensory tasks under controlled changes in temperature, humidity, pressure, and other conditions.

The open-ended concept

The outstanding difficulty with the asymptotic notion of health (which is circumvented by elastic conceptions) is its unattainability. By turning the argument around, one can start with death as a kind of absolute zero and fix no upper limit for human functioning (Bates 1959, p. 59). This may be termed the open-ended conception of health. The outstanding example of this ideology is involved in the attempts to formu late a philosophy of “positive mental health.” While some concepts used by the writers in this tradition, such as “self-actualization,” would fall in the category of asymptotic notions, the criteria of growth, zest, and creativity clearly belong under the open-ended rubric. The theorists of positive mental health share with the authors of the WHO definition and others mentioned above the desire to construct a manner of looking at health which is based “not merely on the absence of disease or in firmity.” However, they go beyond the WHO view of health, and beyond most of preventive medicine generally, in their search for positive goals which are independent of disease (Jahoda 1958). Health promotion in nutrition, for example, aims to pre vent deficiency diseases (a goal which is of the “elastic” type) or persuade people to consume recommended daily norms of nutrients (an asymp totic-type idea). By contrast, “zestful living” does not reach an optimum at certain levels of energy expenditure and could even make people occasionally more prone to injury or disease.

Modern medical practice

In terms of actual health behavior in urban societies, open-ended conceptions are more likey to be put into practice in national parks, beauty parlors, bathrooms, or athletic studios than in the offices of doctors or psychologists. Physicians may recommend vacations, walks in the “fresh air,” or other types of exercise, but this is usually pre scribed for incipient illness or problems of overweight rather than for promoting health as such. In non-Western societies one may find practices aimed at increasing supernatural power, physical strength, prosperity, wisdom, virility, or femininity, which are conceptually and behaviorally integrated with actions to prevent or cure disease. In indus trialized societies, however, increased specialization results in the separation of medical institutions from the religious, esthetic, recreational, and economic spheres. As mentioned above, the focus of Western medicine narrowed as the doctrine of specific etiology of disease became the dominant view. Thus, health promotion through such cus toms as taking cold showers, swallowing vitamin pills to “pep you up,” giving laxatives routinely to children, taking walks, and the like is seldom trans mitted as part of the professional medical system but rather is passed on through relatives, friends, or the mass media.

The attempt of the mental hygienists to develop a new and positive content for the concept of health is further limited by concern for the possibility of their encroachment on other institutions. Brewster Smith (1961, p. 301) has commented on the difficult position of the psychologist who is asked to provide notions of mental health as substitutes for weakened religious values; and Freidson (1961/1962, pp. 125 ff.) has warned about the dangers of bringing questions of nonconformity to moral, legal, or political norms under the umbrella of medicine. In spite of these problems, it may be predicted that scientific medicine will gradually adopt a more open-ended conception of health as the technological tasks of health maintenance in a population with increasing proportions of older people are accomplished and as the relationship between people and their environment once again becomes the central arena of medical concern.

Health beyond the individual

The WHO definition does not specify whether its terms apply only to the health of the individual. In the Greek medical system of the fifth century B.C. and that of some modern Western physicians, as described above, health is seen as an interaction between a person and his surroundings. This type of conception is carried even further in the ideas of many non-Western peoples. Margaret Mead (World Federation for Mental Health 1953, pp. 217 ff.) mentions several examples of “continuity” between the well-being of man and of the soil and between the body and “other bodies of the social unit.” It is but a short step from a focus on these interrelationships to a consideration of the larger unit itself, without necessarily looking at the individual within it at all times.

As the student in schools of public health is often reminded, his “patient” will usually be a community. Public health is thus not only the name of a medical specialty but also refers to the well-being of various publics (Brockington 1958, pp. 19 ff.). The health of other entities, such as families, so cieties, the human species, or the entire ecosphere of this planet, has also been discussed.

The resistance potential of a human collectivity to an epidemic of infectious disease cannot be described as the sum or the average of individual immunity: the degree of resistance in different age groups or the spatial dispersion of the population are crucial in estimating the level of “herd immunity” (Gordon 1958). Mental illness is re garded by a number of psychologists and psychiatrists as a pathological state of an entire family. The illness may be discovered through the request for treatment of a single member who acts as the “messenger boy,” carrying the information about the trouble to the outside world, although he is neither the only one sick nor necessarily the one most seriously disturbed (Gruenberg 1957). There are also some writers who consider it appropriate to label entire societies (for example, Nazi Ger many) as pathological and to wonder if any “healthy adjustment” is possible for individuals living in them (Devereux 1956).

Western medical practitioners almost inevitably put a higher value on prolonging individual life than on the health of the social unit—witness the grotesque situation where catheters, sedatives, exorbitant hospital bills, and oxygen tents prevent a dying man from making a decent and meaningful departure from his relatives. Under different cultural circumstances the reverse evaluation may predominate, as among the Navajo Indians of the southwestern United States, who are more concerned with the well-being of the entire kin group than with the maximum comfort of, say, a congenitally malformed infant (Levy 1962).

For an entire species, health may be regarded as a matter of Darwinian “fitness” for continued survival. Unless a species is approaching death through extinction, however, it may be impossible to diagnose its current degree of fitness. The possibility of using modern medicine to keep alive individuals with genetically inherited diseases and the higher reproductive rate of the impoverished classes have been a focus for alarm by some eugenicists. Whether any real danger of “deterioration” exists for the gene pool of the whole human species is debatable (Medawar I960); but, of course, conceptions of health which regard the proliferation of a “chosen people” as good and their relative submergence by “heathens” or other out-groups as bad are not a recent development (Haller 1963).

The health of the entire ecological system that exists on the surface of the earth can also be evaluated in terms of the survival potential of “life.” Evolution on this planet—inorganic, biological, and social—has in the past moved toward increasing degrees of entropy retardation (Polgar 1961). The catastrophe of nuclear war or the slower but equally irreparable consequences of accelerating population growth are threats to the survival not only of “civilized” man but also of the energy balance of our entire terrestrial ecosystem. According to this view, our future well-being in this world as we know it depends on mankind’s acting deliberately to safeguard and to continue accumulating the ordered energy and information that evolution represents.

Steven Polgar

[See alsoIllness; Medical Care; Mental Health; Public Health. Other relevant material may be found in the articles onCreativity; Epidemiology; Eugenics; Psychosomatic Illness; Social Dar Winism.]


Bates, Marston 1959 The Ecology of Health. Pages 56-77 in Iago Galdston (editor), Medicine and Anthropology. New York: International Universities Press. → The health of human individuals and collectivities seen in relation to the rest of living organisms on the planet. A primary source.

Bing, Elizabeth D.; Karmel, Marjorie; and Tanz, Alfred 1961 A Practical Training Course for the Psychoprophylactic Method of Childbirth. New York: American Society for Psycho-prophylaxis in Obstetrics.

Brockington, C. Fraser 1958 World Health. Harmondsworth (England): Penguin. → A compendium on diseases and the organizations involved in public health. An excellent basic volume.

Cassel, John 1964 Social Science Theory as a Source of Hypotheses in Epidemiological Research. American Journal of Public Health 54, no. 9:1482–1488.

Devereux, George 1956 Normal and Abnormal: The Key Problem in Psychiatric Anthropology. Pages 23-48 in Anthropological Society of Washington, Some Uses of Anthropology: Theoretical and Applied. Washington: The Society. → Discusses the usefulness of the culture concept, with particular emphasis on the shaman. A unique and illuminating essay.

Dubos, Renej. (1959)1961 Mirage of Health, Utopias, Progress, and Biological Change. New York: Harper. → A discourse on health and disease—their history, treatment and characteristics—by an eminent biologist. A primary source.

Firth, Raymond 1959 Acculturation in Relation to Concepts of Health and Disease. Pages 129-165 in Iago Galdston (editor), Medicine and Anthropology. New York: International Universities Press. → A fine essay on the sociocultural context of medical practice. A primary source.

Freidson, Eliot 1961/1962 The Sociology of Medicine: A Trend Report and Bibliography. Current Sociology 10/11: 123–192. → The best sociological summary.

Gennep, Arnold van (1909) 1960 The Rites of Pas sage. London: Routledge; Univ. of Chicago Press. → First published in French. A classic anthropological essay on birth, puberty, marriage, childbirth, and death.

Gordon, John E. 1958 Medical Ecology and the Public Health. American Journal of the Medical Sciences 235:337–359. → A summary of Gordon’s views, with examples from numerous investigations.

Gruenberg, Ernest M. 1957 Socially Shared Psychopathology. Pages 201-225 in Explorations in Social Psychiatry. Edited by A. L. Leighton et al. New York: Basic Books.

Haller, Mark H. 1963 Eugenics: Hereditarian Attitudes in American Thought. New Brunswick, N.J.: Rutgers Univ. Press. History and evaluation of the eugenics movement in the United States.

Huard, Pierre A.; and Wong, Ming 1959 La medecine chinoise au cours des siecles. Paris: Dacosta. → The best contemporary summary of Chinese medicine in a Western language.

Jahoda, Marie 1958 Current Concepts of Positive Men tal Health. New York: Basic Books. → A good synopsis of the field.

King, Stanley H. 1963 Social Psychological Factors in Illness. Pages 99-121 in Handbook of Medical Sociology. Edited by H. E. Freeman et al. Englewood Cliffs, N.J.: Prentice-Hall. → Psychological aspects of doctorpatient relations, as well as of illness.

Levy, Jerrold E. 1962 Comment on “Health and Hu man Behavior” by Steven Polgar. Current Anthropology 3:186–187.

Lewis, Aubrey 1953 Health as a Social Concept. Brit ish Journal of Sociology 4:109–124. → Separates health from social well-being, delineating operational criteria for physical and mental illness in the “asymptotic” tradition.

Medawar, Peter B. 1960 The Future of Man. New York: Basic Books; London: Methuen. → An essay on human genetics; grapples with many difficult and fundamental value problems.

Mering, Otto Von; and Earley, L. William 1965 Major Changes in the Western Medical Environment: Impact of Changes in Care of Undifferentiated Disorders. Archives of General Psychiatry 13:195–201.

Newell, Kenneth W. 1957 Medical Development Within a Maori Community. Health Education Jour nal 15:83–90.

Nurge, Ethel 1958 Etiology of Illness in Guinhangdan. American Anthropologist New Series 60:1158—1172.

Paul, Benjamin D. 1953 Mental Disorder and Self-regulating Processes in Culture: A Guatemalan Illustration. Pages 51-68 in Milbank Memorial Fund, Interrelations Between the Social Environment and Psychiatric Disorders. Proceedings, No. 29. New York: The Fund. → Describes the sequence of events in serving patients and their significance for treating disturbances in social relationships.

Pflanz, Manfred 1964 Der unklare Fall. Miinchener medizinische Wochenschrift 106:1649–1655. → A discussion of the characteristics of patients, physicians, and medical thought, as these bear on the frequency of undifferentiated diagnoses in medical practice.

Polgar, Steven 1961 Evolution and the Thermody-namic Imperative. Human Biology 33:99–109. → A development of four principles in organic and social evolution, from which a value position is derived.

Polgar, Steven 1962 Health and Human Behavior: Areas of Interest Common to the Social and Medical Sciences. Current Anthropology 3:159–205. → A charting of the field, with an extensive bibliography.

Polgar, Steven 1963 Health Action in Cross-cultural Perspective. Pages 397-419 in Handbook of Medical Sociology. Edited by H. E. Freeman et al. Englewood Cliffs, N.J.: Prentice-Hall. → An essay-review on the values and notions relevant to health, on medical practitioners, and on cross-cultural health programs.

Riese, Walther 1953 The Conception of Disease: Its History, Its Versions and Its Nature. New York: Philo sophical Library. → Fourteen types of disease conceptions, almost exclusively from the Western tradition.

Rosen, George 1958 A History of Public Health. New York: Md Publications..

Shiloh, A. 1958 Middle East Culture and Health. Health Education Journal 16:232–244.

Sigerist, Henry 1951-1961 A History of Medicine. 2 vols. New York: Oxford Univ. Press. → Volume 1: Primitive and Archaic Medicine. Volume 2: Early Greek, Hindu, and Persian Medicine. A lucid, scholarly, and thorough history.

Smith, M. Brewster 1961 “Mental Health” Reconsidered: A Special Case of the Problem of Values in Psychology. American Psychologist 16:299–306. → An excellent attempt to cut through the conceptual dilemma in order to arrive at operational guidelines for applied psychology.

Steiger, W. A. et al. 1962 A Definition of Comprehensive Medicine. Journal of Health and Human Behavior 1:83–86.

U.S. Department Of Health, Education, And Welfare, Division Of Vital Statistics 1966 ConceptualProblems in Developing an Index of Health, by Daniel F. Sullivan. Washington: Government printing office.

World Federation for Mental health (1953) 1955 Cultural Patterns and Technical Change. Edited by Margaret Mead. New York: New American Library.→ A very useful overview in the form of a collage of case histories and topical discussions.

World Health Organization 1946 Constitution of the World Health Organization. Geneva: The Organization.

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Health and Disease


HEALTH AND DISEASE. The relationships among food, health, and disease are myriad and complex. We consume food every day, and it provides the resources we need to carry out life-sustaining functions. Hence it comes as no surprise that one's diet can affect profoundly one's daily and long-term physiological health and wellbeing. Qualities of a diet and the foods that comprise it have the potential to make one sick, but they also can act to reduce one's risk of acute or chronic diseases.

All of the formal medical traditions of the world recognize a close connection between diet and an individual's health. One theme common to Mediterranean, Middle Eastern, and South and East Asian traditional medical systems is the ascription of humoral qualities to foods (for example, foods that are "heating" or "cooling" to the body). In these traditional systems, an individual's diet is manipulated to include or exclude foods with specific properties in order to correct putative humoral imbalances or disease states. In contemporary biomedicine, the link between food and disease most often is articulated with regard to the compositional qualities of foods and the ways that diets high or low in specific foods (and hence nutrients and other plant constituents) have harmful or beneficial effects on the body.

Benefits of Nutrient Diversity

There are numerous ways in which diets comprised of specific foods containing or lacking a given nutrient contribute to health or disease. For example, a diet that includes few or no animal products may result in anemia due to a deficiency in iron and/or vitamin B12. On the other hand, a diet high in animal products but low in fruits and vegetables may contribute to specific vitamin deficiencies. Scurvy (a disease caused by vitamin C deficiency) was recognized first among sailors on long-distance sea voyages, as they had no source of fresh fruits or vegetables. An unprocessed corn-based diet is known to result in the disease pellagra, caused by a deficiency of niacin, one of the B vitamins. Up through the early twentieth century, there was a well-defined "pellagra belt" through the southern United States, where corn was consumed widely.

A diet comprised of diverse foods generally is considered to be the best way to prevent nutrient-deficiency diseases. Early humans lived by hunting and gathering, and they ate a broad array of plant and animal foods, although this varied by season and geography. Modern hunter-gatherers of the Kalahari Desert in southern Africa are known to exploit more than eighty species of plant foods, and no specific nutrient deficiencies have been reported among these groups. However, with the transition to agriculture, which happened in many parts of the world around 10,000 years ago, dietary diversity declined notably as populations began to cultivate a narrow array of staple crops (such as wheat, rice, potatoes, and millet). Iron deficiencies and severe growth deficits due to undernutrition become apparent in the skeletons of early farmers.

Effects of Food Processing

Some of these nutritional problems were resolved as populations evolved different means of processing staple foods that enhanced dietary nutrient profiles. Indeed, in the postagricultural period, food-processing techniques became crucial for reducing the negative health impacts of reliance on a few foods. Native populations of the Americas that had a long tradition of reliance on maize (corn) prepared it in such a way as to avoid the problem of niacin deficiency. Corn was boiled in a solution containing lime (calcium carbonate, ash, etc.); this process resulted in the liberation of niacin from an undigestible complex, and also improved the food's amino-acid balances. When corn was introduced to Europe during the Columbian period, the lack of a tradition for its processing led to outbreaks of pellagra. A similar example is the leavening of wheat to make bread, or fermentation to make beer. Both of these processes increase the bioavailability of the minerals calcium, iron, and zinc. When soybeans are processed into bean curd, as is common in East Asia, they lose their protease inhibitors, which interfere with protein digestion.

On the other hand, it is also the case that some food-processing techniquessuch as heating, boiling, or dryingcan destroy vitamins in foods. Vitamin C degrades in the presence of heat and aridity; folic acid and thiamine likewise are sensitive to heat. Some of the other B vitamins break down in the presence of alkaline or acidic conditions. Others, such as vitamins B6 and B12, are quite stable under most cooking conditions. Milling and polishing rice into smooth white grains, which are valued highly in East Asian cuisine, reduce the protein and thiamine content of rice, and contribute to the risk of the disease beriberi (thiamine deficiency). Industrial processing of foods often reduces their nutrient profile, but many foods, especially those that are consumed widely such as cereals, are enriched to replace lost nutrients. In addition, grilling or broiling meats until they are well-charred has been associated with the production of the chemical compound Benzo(a)pyrene, which has been linked to gastrointestinal cancers.

Nonnutritive Food Components

When diets are derived largely from plant foods, particular combinations of food are known to improve the overall dietary quality, particularly with respect to the balance of essential amino acids. Corn, for example, is low in the amino acids lysine and tryptophan, but in native American cuisine, corn is often combined with legumes that are rich in those amino acids. Likewise, the combination of rice and legumes can provide the full array of essential amino acids. A peanut butter sandwich, a staple in the diet of many American children, contains complementary amino acids from the wheat and peanuts.

However, it is not only the nutrient composition of foods that is relevant to disease. Other qualities of foods especially plant foodsrecently have been found to contain other chemicals that reduce the risk of certain diseases. Phytochemicals derived from plant foods may reduce the risk of some cancers, while others may protect against heart disease and/or diabetes. Some potentially important phytochemicals include polyphenols (in red wine and green tea) and carotenoids (in orange, yellow, and green vegetables). Many of these have been found to have antioxidant effects and may prevent cell damage from oxygen-free radicals. Widespread consumption of red wine has been credited by some with the "French Paradox," the observation that, although the French tend to eat foods high in fat, their consumption of red wine may offset some of the risk of cardiovascular disease usually associated with such diets. Phytoestrogens, a form of isoflavones found in legumes such as soybeans, may reduce the risk of many cancers, especially breast cancer, by binding to estrogen receptors, and these also may reduce bone loss associated with osteoporosis. Proteins in soybeans also may reduce cholesterol levels and thus reduce the risk of heart disease. The organosulfur constituents of garlic may inhibit platelet aggregation and reduce blood lipids, thereby reducing the risk of coronary heart disease. Tannins (found in tea, coffee, cocoa, red wine, and some legumes and grains) and phytates are hypoglycemic, and may contribute to reduced risk of diabetes.

Other plant compounds have links to infectious disease, such as the protozoan disease malaria, which is a common disease (and often life-threatening) in tropical and semitropical areas. Manioc (Manihot esculenta ; also called cassava or yuca), a widely cultivated root crop in the tropics, contains cyanogens, which appear to inhibit the growth of the malaria parasite in red blood cells. Likewise, fava beans contain vicine, a potent oxidant that disrupts malarial reproduction in red blood cells. However, individuals who are deficient in the enzyme G-6PD (a deficiency most common in Mediterranean populations) are susceptible to the potentially fatal anemia, favism, because their red blood cells are extremely vulnerable to destruction by potent oxidants such as vicine.

Many secondary compounds in plants do not have such salutary effects, or their benefits are tempered by potential negative effects on health. The cyanogens in manioc, lima beans, and other foods can interfere with thyroid function, glucose metabolism, growth and development, and other important physiological functions. Cruciferous vegetables such as cabbage contain thiocyanate compounds that act as goitrogens, and thereby contribute to thyroid disease. Tannins, which are distributed widely among plant foods, inhibit protein digestion and interfere with iron absorption. The ingestion of solanine, a glycoalkaloid found in commercial strains of potatoes that have been exposed to light, or in many wild varieties, can lead to serious gastrointestinal and neurological symptoms. Interestingly, traditional modes of consuming potatoes among Andean populations appear to reduce the risk of solanine exposure; their potatoes are consumed often with a clay-based slurry, which effectively detoxifies them.

Food-Consumption Concerns Linked to Population Profiles

There are cases in which the health effects associated with the consumption of particular foods vary in significant ways among diverse populations. For example, the ability to produce the enzyme lactase (which breaks down the milk sugar lactose) in adulthood is rare among human populations. This ability persists in highest frequencies through adulthood among northern Europeans and pastoral populations in Africa and other areas. Fresh milk consumption played an important role in maintaining health in the history of these populations, and they evolved lactase persistence as a dietary adaptation. When adults with low levels of small-intestinal lactase activity consume fresh milk (the food highest in lactose), they often experience cramps, bloating, diarrhea, and other forms of gastrointestinal distress. This is less of a problem when milk is consumed after processing into yogurt or cheese, as lactose is either fermented or removed during their production.

In populations that only recently have begun relying on wheat production there is a high frequency of celiac disease, an allergic response to wheat protein (gluten). There is some suggestion that African Americans may be more sensitive to salt than are other sectors of the population, and that, consequently, salt consumption by African Americans increases blood pressure and contributes to an incidence of hypertension greater than in other groups.

In the most general sense, both underconsumption and overconsumption of foods can lead to chronic disease. Not surprisingly, these two ends of the consumption spectrum tend to occur in poor and wealthy populations, respectively. It is estimated that more than 1.2 billion people suffer from deficiencies of calories and protein. A similar number suffer from problems related to the overconsumption of calories. Both are associated with deficiencies of micronutrients. It has been suggested that more than half of the world's disease burden derives from nutrition-related sources.

Overconsumption of calorie-rich foods became the norm in wealthy countries during the late twentieth century. Such foods became mass produced, more readily available, and relatively inexpensive. Today supermarket shelves are lined with potato chips, candy, cookies, crackers, soda, and all kinds of other calorie-dense foods. Fast-food restaurants specialize in ever-larger servings of high-calorie foods that are quickly prepared and consumed. Most of these are highly processed, and although they are rich in calories, they are often low in vitamins, minerals, and phytochemicals. It is widely accepted that, when combined with a sedentary lifestyle, diets high in such foods contribute to a broad array of chronic health conditions, most significantly cardiovascular disease (CVD), diabetes, cancer, and hypertension. It is now estimated that more than half of Americans are overweight, and almost one-quarter are obese, which is itself a risk factor for these diseases. In addition, an increasing number of children are now obese, and "adult-onset" (Type 2) diabetes is appearing with alarming frequency in adolescents. More than 75 percent of all mortality in the United States is due to CVD and cancer, but death rates from stroke and heart attacks have declined since the 1970s. This has been attributed, in part, to reduced consumption of saturated fat from red meat, whole milk, butter, and lard. There are several studies indicating that a low-fat diet based largely on vegetables, fruits, whole grains, legumes, with relatively small amounts of animal protein (especially from fish) is associated with increased longevity and reduced risk of chronic disease.

Problems related to the overconsumption of high-calorie foods are not unique to the industrialized world. As countries are integrated into the global economy and populations increasingly become urbanized, there has been a global shift in dietary patterns and health conditions that appear to accompany those new consumption habits. Interestingly, such changes are remarkably consistent across countries, and may reflect a panhuman preference for foods rich in calories, which historically have been quite limited in the diet. Generally the consumption of fats and sweets has increased, and the use of traditional whole-grain foods and traditional modes of processing has declined. Fast-food outlets such as Kentucky Fried Chicken and McDonalds have become ubiquitous in urban centers throughout the world. Active lifestyles are being replaced with sedentism, as people move away from subsistence agriculture into clerical and factory jobs. As a result, the chronic diseases that heretofore had predominated in wealthy industrialized countries are becoming globalized. For example, the global diabetes rates seen in 2000 are expected to double by 2025, with the majority of that growth occurring in developing countries.

On the other hand, undernutrition, also referred to as protein-energy malnutrition (PEM), often occurs under conditions of food scarcity and is associated with a wide range of negative health effects. More than 10 percent of the world's population suffers from chronic hunger, and undernutrition may be responsible for as many as twenty million deaths per year. It is important to realize that hunger is not the result of too little food being produced for too many people in the world; it is essentially a problem with the way that food is distributed unevenly among the world's populations. Children are especially vulnerable to PEM, as they have higher protein and energy needs per unit of body weight than do adults. When calories and protein are chronically scarce in childhood, permanent stunting and retarded development occur. In its acute form, PEM results in wasting (dramatically reduced weight relative to height) and it is potentially fatal. More routinely, PEM increases vulnerability to infectious disease, since energy, protein, and certain vitamins and minerals play crucial roles in immune function. In environmental contexts in which infectious disease (especially diarrheal disease) is common, the combination of PEM and infection can provoke a rapid deterioration of health that can lead to death. A common stage for this progression to manifest itself is weaning, the period when children make the transition away from breast milk (which contains nutrients and disease-suppressing maternal immunoglobulins) to an adult-type diet. It is not uncommon for children to become more vulnerable to infection when they are weaned prematurely and are unable to consume sufficient nutrientdense foods to maintain growth.

In the 1800s, baby bottles were developed and cow's milk was developed into infant formula as an alternative to breast milk. The practice of formula-feeding peaked in the United States in the years following World War II; breast-feeding is now on the rise again in most parts of the world, although it remains uncommon past the early months in most industrialized countries. Most research amply demonstrates the health benefits of breastfeeding: substitution of formula for breast milk is associated with increased risks of numerous health problems including SIDS (sudden infant death syndrome), ear infections, diabetes, breast cancer, and allergies.

Controversy erupted in the early 1970s over the promotion of formula by multinational corporations in the developing world. Formula was marketed heavily and inappropriately, and health personnel began to encourage mothers to feed their children formula rather than nurse them. Formula, which was costly, often was prepared in dilute form with contaminated water. Its use in this way increased infant morbidity and mortality and generated much attention among the media and international health organizations, ultimately resulting in a ban on formula promotion by multinational corporations.

As the links between diet and disease have become more widely known, there has been a trend toward more healthful eating habits in industrialized societies. However, this trend is not uniform within such populations. Numerous studies have shown that obesity, the eating habits that contribute to it, and the diseases associated with it, especially diabetes, have increased among lower socioeconomic groups. The reasons behind this trend are complex, but as noted above, foods high in starches, fats, and sugars are now cheap and readily available. Those high in protein (meat, dairy products) and fresh fruits and vegetables are relatively less accessible and more expensive, and are consumed less commonly by the poor. Moreover, in the United States, fast-food outlets are locating preferentially in areas serving poorer communities. This has led to the curious, yet commonplace, phenomenon in wealthy countries whereby weight is correlated inversely with wealth. Historically, of course, the reverse would have been the case, as is still evident in many developing countries.

See also Anthropology and Food; Baby Food; Disease: Metabolic Diseases; Fast Food; Food Politics: United States; Lactation; Malnutrition; Medicine; Milk, Human; Niacin Deficiency (Pellagra); Nutrients; Nutrition; Obesity; Paleonutrition, Methods of; Political Economy; Population and Demographics; Salt; Sodium; Vitamins.


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Gardner, Gary, and Brian Halweil. Underfed and Overfed: The Global Epidemic of Malnutrition, edited by Jane A. Peterson. Worldwatch Paper 150. Washington, D.C.: Worldwatch Institute, 2000.

Jackson, Fatimah Linda Collier. "Secondary Compounds in Plants (Allelochemicals) as Promoters of Human Biological Variability." Annual Review of Anthropology 202 (1991): 505546.

Johns, Timothy. "The Chemical Ecology of Human Ingestive Behaviors." Annual Review of Anthropology 28 (1999): 2750.

Katz, Solomon H. "Food and Biocultural Evolution: A Model for the Investigation of Modern Nutritional Problems." In Nutritional Anthropology, edited by F. E. Johnston. New York: Alan R. Liss, 1987.

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Liebman, Bonnie, and David Schardt. "Diet and Health: Ten Megatrends." Nutrition Action 28, no. 1 (January/February 2001): 312.

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McGee, Harold. On Food and Cooking: The Science and Lore of the Kitchen. New York: Simon and Schuster, 1984.

Stuart-Macadam, Patricia, and Katherine A. Dettwyler, eds. Breastfeeding: Biocultural Perspectives. New York: Aldine de Gruyter, 1995.

Van Esterik, Penny. Beyond the Breast-Bottle Controversy. New Brunswick, N.J.: Rutgers University Press, 1989.

Wardlaw, Gordon M., and Paul M. Insel. Perspectives in Nutrition. New York: Mosby, 1996.

Andrea S. Wiley

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Health and Disease


Health and disease seem at first glance to be obvious and opposing concepts. We are either healthy or suffering from some disease. In practice, however, health and disease are neither clearly defined nor mutually exclusive. Asthmatics and diabetics have won Olympic gold medals, and amputees can live to a ripe old age. "Healthy" people in their eighties cannot do things they could easily have done half a century before; they may still be able to perform tasks they could not have as healthy infants. Conditions that would be perceived as a disease in one society might be considered perfectly normal in another.

Health is a more problematic and conditional state than is disease, and it is generally less visible historically. It is less likely to be noticed by the individual or commented on by healers or philosophers. Often, health is simply the default mode, the condition to which people revert after they recover from some illness. Illness is of course not the same as disease. The former is a subjective experience, suffered by a person; the latter is more objective, in that others, especially medical practitioners, share in its conceptualization. The diagnosis, or naming, of the disease generally presupposes some notion of its cause. There may be different frameworks of putative causation operating between patients and their healers. The patient may believe he or she fell ill because of exposure to the cold or consumption of the wrong kind of food. The doctor may have other ideas. For most of human history, however, doctors and patients shared similar causative cosmologies. With the rise of modern biomedicine, the potential divergence of the explanatory frameworks increased. This separation of the conceptual worlds of doctor and patient is part of the power, and the problems, of modern medicine.

More constant are the normative dimensions of health and disease. Health, however conceived, has positive qualities, disease negative ones. Aesthetics plays a large part in contemporary judgments on these matters. Sumo wrestlers and weight lifters are perceived as healthy, even if their life expectancies may be less than those of ninety-pound weaklings. Straight teeth are considered healthier than crooked ones. Plump women in some cultures are considered healthier than their leaner sisters; in other times and places, the reverse is the case. Sunbathing is a relatively recent phenomenon among the lighter skinned races; malignant melanoma has caused a reevaluation of the relative merits of the aesthetic and the medical.

All of these examples point to the complexity and historical contingency of perceptions of health and disease. Following Alexander Pope's dictum, "this long disease, my life," this essay will use disease as the standard and assume that notions of health are somehow implicit in the historical perception of disease.


In preliterate societies, disease was often assumed to be the product of one of two opposing occurrences: object intrusion or spirit loss. The intrusion of some foreign object was invoked to explain diseases marked by pain, restlessness, and other acute symptoms. Spirit loss resulted in wasting, lethargy, and other signs of debility. These grand divisions, corresponding very roughly to "noisy" (acute) diseases and "quiet" (chronic) ones, recur throughout history. In preliterate societies, the explanations were embedded within magico-religious frameworks, and the remote causes of disease might be witchcraft, malevolent spirits, or individual transgression of some cultural taboo. Healing was often a communal affair, and the principal healer generally combined the offices of priest and doctor. While the conceptual framework was religious or magical or both, the steps toward healing, or disease prevention, rationally followed the assigned causes. Notions of health generally incorporated aspects of fecundity or potency and are reflected in famous prehistoric works of art.

Literate Near Eastern communities in Egypt, Mesopotamia, and elsewhere developed medical systems that indissolubly mixed the religious and the medical, and the priest-physician was a central figure in them all. Myths of a golden age, when disease did not exist, were common, as was the tacit assumption that individual transgression could be implicated as the root cause of disease.

Three great systems of medicine with great staying power developed in the centuries before the Common Era. These arose in Greece, India, and China. Modern Western biomedicine can be traced to the work of Hippocrates and his followers. The ayurvedic system in India developed autonomously, as did Chinese medicine. The latter two systems still have many followers and have been more impervious to change than has Hippocratic medicine. There are a few, probably incidental, commonalties in the three systems. In each of them, bodily fluids (humors) and spirits (pneuma) were more important than the solid parts in determining health and disease. Longevity was a more explicit goal of health than was fertility or potency. Notions of balance were central to each system.

There are also important differences. The Chinese associated health with plumpness (Buddha is always depicted as rotund), whereas Greek sculptures of idealized athletes show the taut muscular development that Western values still identify with health and vitality. The Chinese polar principles of yin and yang have no obvious parallels in Western thought. The three Indian humors (dosa ) of wind, bile, and phlegm cannot be equated to the four humors of Greek medicine.

The series of treatises written between the fifth and second centuries b.c.e. by Hippocrates and his followers provide the touchstone of modern Western biomedicine. So powerful is this legacy that both the dominant scientific biomedicine and the alternative Western medical cosmologies, such as homeopathy, naturopathy, osteopathy, chiropractic, and hydropathy, all claim descent from this "father" of Western medicine. The Hippocratics naturalized disease, making it part of ordinary human existence, rather than the result of supernatural forces. They also reinforced the notion of health as a balance of the four humors, disease occurring when one or more of the humors was in excess or deficiency.

Greek humoralism was one of the most powerful explanatory systems ever devised within medicine. It was linked to Greek natural philosophy (the four humors having their counterparts in the four elements, air, earth, fire, and water) and contained a framework that made good sense of the human life cycle, individual temperament, and the role of the environment in health and disease. One Hippocratic treatise, Airs, Waters, Places, is simultaneously a subtle treatise on environmental medicine and a foundation document on the formative role of place and topography on human culture.

The Hippocratics always insisted that the physician was the servant of nature. Through their important doctrine of the healing power of nature (vis medicatrix naturae), they interpreted the phenomena of the bedsidesweating, vomiting, diarrhea, jaundice, productive coughsas evidence that the body was trying to rid itself of its excessive humors or to restore defective or deficient ones. Disease was for them an individual affair, based on the person's stage in the life cycle, normal temperament, sex, occupation, and other individualized factors. They elaborated a system of hygiene, advice to the individual on how he or she might preserve health and achieve longevity, through diet, exercise, and mode of living. Humoral medicine made no sharp distinction between mental and bodily disorder, explicating melancholy, mania, and hysteria along identical lines as fevers, cancer, or chronic wasting diseases such as phthisis.

Hippocratic humoralism was by no means the only medical system developed during the Mediterranean antiquity, but it was the most influential one, especially after Galen (c. 129c. 199/216) identified with it and consolidated and extended its nuances. Hippocrates and Galen enjoyed positions of un-rivalled prestige for more than a millennium. Galen's monotheism and philosophical bent especially appealed to elite physicians after Christianity became the dominant religion of the West. The otherworldly dimension of Christianity during the medieval period meant that bodily health and disease could be devalued, in pursuit of the eternal felicity of the other world, but medical orthodoxy still operated within the humoral framework. Both religion and magic also offered important alternative interpretations, and both cause and cure of disease could be sought in the realms of the supernatural. Holy shrines and pilgrimages became part of the simultaneous expiation of sin and restoration of health. Several of the seven deadly sins (gluttony and sloth, for example) were also intertwined with causative explanations of disease. Indeed, sloth (also called acedia) was actually medicalized into a diagnostic category and seemed to be especially common among monks who found it difficult to leave their warm beds for early-morning prayers.

Early Modern Concepts

The early modern period witnessed great changes in physical science, with the decline of Aristotelianism and the mechanization of the world picture during the period dubbed the scientific revolution. Notions of health and disease reflected some of these developments, although continuities are also obvious. Manuals of health and longevity became popular, as health became a desirable goal in societies now concerned with investigating the wider world and the stars above. As always, health was generally associated with moderation, especially through the regulation of what were called the six "nonnaturals": air, food and drink, sleep and wakefulness, retentions and excretions, motion and rest, and the affections of the mind. An Italian nobleman, Luigi Cornaro (c. 14631566), wrote in his old age a treatise on hygiene, based on his own experience of moderate living. It was widely translated and remained in print for several centuries. Although the explanatory framework would differ today, Cornaro's treatise is filled with advice that would not be out of place in a contemporary lifestyle medical manual.

There was much continuity in advice manuals on health for a long time after Cornaro, but ideas about the causes and mechanisms of disease began to change. Hippocratic humoralism had much staying power, but doctors such as Paracelsus (14931541) and Jan Baptista van Helmont (15791644) elaborated new medical systems. Van Helmont linked physiological function in both health and disease with a vital power that he identified with the archeus, a principle he associated with each organ. It had the effect of separating the disease from the body of the individual sufferer, as the archeus had some sort of independent existence. Van Helmont inclined toward chemical explanations of disease, but other doctors leaned toward mechanical models of both normal and pathological functions, following in the wake of the triumphant natural philosophers such as Galileo Galilei (15641642) and Isaac Newton (16421727). Iatrochemists and iatromechanists, as they were called, vied with each other for theoretical dominance from the late seventeenth century.

In the midst of all these theoretical concerns, one clinician remained true to Hippocratic humoralism. Thomas Sydenham (16241689), the "English Hippocrates," approached clinical medicine without much concern for the newfangled chemistry or mechanical physiology. He left superb descriptions of a number of diseases, including gout, smallpox, and hysteria, insisting that medicine was an empirical affair, ultimately based on careful observation and the trial-and-error use of remedies. One such remedy, Peruvian bark (which contains quinine), so impressed him in its capacity to extirpate "agues" (malarial fevers), that he came to believe that diseases could be classified in the same way that naturalists classified plants and animals. Nosology, or disease classification, became a preoccupation among eighteenth-century physicians. It came to be based primarily on symptoms, and the number of disease categories multiplied. Sydenham's remarks on the specificity of diseases came into their own in the late nineteenth century, when germ theorists began to identify the disease with the germ that was proposed as its causative agent.

Hippocratic humoralism gradually lost its persuasiveness during the eighteenth century, as doctors turned to the blood, nervous system, or glands as the primary foci of disease causation. At the same time, pathologists such as Giovanni Morgagni (16821771) began to note consistent patterns of structural changes in the bodies of patients they autopsied and to attempt to correlate these changes in the organs and tissues with the diseases they had diagnosed and the symptoms that the patient had suffered from during life. This clinicopathological correlation became the basis of the hospital medicine that flourished in Paris after the French Revolution.

The Modern Period

In order better to follow the course of disease in the living, French clinicians routinized systematic physical examinations of their patients. Jean Corvisart (17551821) developed percussion, tapping on the thorax and abdomen, to demarcate enlarged organs, collections of fluid, or tumors, and René Laennec [17811826] invented the stethoscope in 1816. Paris itself became a world center of medical education, and foreign students exported the French way of doing things throughout the Western world. French medicine was based primarily on the diseases of the organs, such as the heart, lungs, or liver. The development of better microscopes in the 1820s encouraged doctors to push pathological analysis into the tissues (a concept popularized by the French clinician M. F. X. Bichat [17711802]), and by the late 1830s, cell theories had been elaborated by German scientists such as Matthias Jakob Schleiden (18041881), for plants, and Theodor Schwann (18101882), for all living organisms. Rudolf Virchow's (18211902) Cellular Pathology (1858) put the cell at the heart of medical reasoning.

At about the same time, the work of microbiologists such as Louis Pasteur (18221895) and Robert Koch (18431910) showed the causative importance of bacteria and other microorganisms in a host of diseases. The germ theory of disease had dramatic practical spin-offs for medicine and public health, but it also separated the "disease" (the microorganism) and the victim of disease. Without the tubercle bacillus, there could be no tuberculosis. For some doctors, the disease could now be equated with its causative organism.

The germ theory was never without problems. Many clinicians considered germs as either incidental to or the result of disease, rather than its cause. Enthusiastic researchers found germs for many diseases, such as pellagra and cancer, which subsequent investigations would disprove. Some social activists complained that obsession with germs deflected concern from other factors that also influenced health, such as housing or inequalities of wealth. Why two individuals exposed to the same germ might have completely different reactions highlighted important host-parasite interactions. The range of agents causally associated with disease has been extended from the bacteria to include worms, plasmodia, amoebas, viruses, and, more recently, prions. Always, anomalies have driven researchers back to the bedside, community, or laboratory.

Since the mid-nineteenth century, the thrust of biomedical levels of disease explanation has been toward ever more minute categories: intracellular elements, chemicals, and molecules with known compositions and structures. Molecular biology is the preeminent science of the present day, created just before, but reaching powerful maturity after, the elucidation of the structure of DNA in 1953 by James Watson and Francis Crick. The biological importance of DNA had been recognized before Watson and Crick's work, but understanding its structure provided a model of how this long-chained molecule, found in the chromosomes of the cell's nucleus, controlled the inherited continuity that is characteristic of living organisms.

Modern biomedical research has revealed many of the mechanisms of disease at the molecular level. The first "molecular disease," sickle-cell anemia, was identified by Linus Pauling in 1949 as the result of a minor structural (but large functional) change in the hemoglobin molecule. Molecular medicine has progressed rapidly since the mid-twentieth century, with the Human Genome Project offering the prospect of much greater knowledge about the role of genetic factors in health and disease. Genetic information also creates a host of ethical problems, such as confidentiality, insurance premiums, employability, and advice on parenthood. Critics argue that it is eugenics in new dress; advocates insist that the knowledge itself is neutral and its use is a matter for society to sort out.

By the twenty-first century the concept of disease had been diluted, as we have all been medicalized. Acts, desires, and choices that in previous generations would have been conceptualized within moral, religious, or legal frameworks could now be attributed to disease. Eating disorders, suicide, many forms of criminality or deviancy, stress, and many other "facts" of modern life are often included within disease categories. Homosexuality has been a normal stage of the life cycle, a sin, a crime, a disease, and a life choice in different periods within Western society. "Mental" diseases continue to carry a moral burden.

If modern medicine has been expansionist in the field of disease, it has been less successful in assimilating health into its orbit. The more we know, the more prevalent disease, or potential disease, seems to be. Orthodox medical advice about health is largely statistical in its foundations and behavioral, not medical, in its recommendations. The Hippocratic injunction to moderation is still at the heart of Western medicine. What is "normal"that is, healthyis often based on epidemiological surveys, actuarial information, and cultural values. Despite the enormous power of modern biomedicine, health and disease still have important cultural, aesthetic, and moral dimensions to them.

See also Biology ; Eugenics ; Hygiene ; Medicine ; Psychology and Psychiatry ; Scientific Revolution .


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Conrad, Lawrence I., et al. The Western Medical Tradition: 800 b.c.1800 a.d. Cambridge, U.K.: Cambridge University Press, 1995.

Cooter, Roger, and John Pickstone, eds. Medicine in the Twentieth Century. Amsterdam: Harwood, 2000.

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Gilman, Sander L. Health and Illness: Images of Difference. London: Reaktion, 1995.

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W. F. Bynum

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health is commonly thought of as the absence of disease, and indeed it is difficult to discuss one without the other. Equally problematic is the consideration of the health of the body apart from the state of the mind or the spirit, because historically the topics were closely connected, especially before the seventeenth century. Even with these difficulties in mind, it is still possible to focus on certain notions about the health of the human body as a natural state and about how this natural state could be restored or maintained.

One idea about health that unites many cultures, from the classical Indian, Mesopotamian, Egyptian, ancient Greek, sub-Saharan African, Semitic, and native American, is the notion that there was a time when the human body existed in a perfect state of health and when no diseases beset it. People lived in harmony with nature, in a childlike state of material plenty and spiritual obedience. Bodily ills came into the world, so many stories go, when a ‘sin’, often one of disobedience, angered divine authority. One thinks of the myth of Pandora's box or the expulsion of Adam and Eve from the Garden of Eden, as told in Genesis, as examples, but other cultures provide many more such tales. Stories about original sin and the fall from grace are, in short, as common as creation myths in their explanations for why humanity no longer experiences natural health and, in some cases, long physical life.

Such myths carry in them crucial meanings for understanding the history of the body and its health that are with us still. The idea that there was a time when perfect health existed naturally is a powerful one. The author of Genesis wrote of painless childbirth before the Fall, and of, even after it, the remarkable age and sexual prowess of the Patriarchs. These stories also link health, or lack of it, to moral or religious conduct, and often join good health to a vigorous old age.

If perfect bodily health existed once, some argued, it could exist again. The restoration of balance and harmony with nature and with the divine was commonly offered as a way to achieve this restoration. Taoist thought sees good health as a balance between the opposing forces of Yin and Yang, which exist in the individual as well as in the world at large. The ancient Greeks viewed good bodily health as the duty of the aristocracy, along with military service and good governance. Medical texts are among the earliest surviving philosophical writings of the Greeks, indicating an eager audience for this type of advice.

Ancient Greek notions are perhaps the most important for defining how health would be regarded, at least in European and Islamic cultures. Most important is the nearly universal idea of microcosm and macrocosm. Very simply put, the body (microcosm) was thought of as a part of the larger world of nature (macrocosm). The four elements of nature: earth, air, fire, and water, and the four qualities: hot, cold, moist, and dry, found their counterparts within the body in the four humours: blood, which was hot and moist; choler, which was hot and dry; phlegm, which was cold and moist; and melancholy, which was cold and dry. Health lay in balancing these humours within the body through a regimen consisting of diet, exercise, and regulation of the emotions. Moderation and balance in all these natural factors was the road to good health and long life. Indeed, the Greeks counted gymnastics among the liberal arts, along with rhetoric and logic, as activities proper to a gentleman and ones leading to moral virtue.

Roman Stoic philosophers and Christian thinkers who followed after them held physical health in rather less esteem. Stoics sought to free themselves from bodily concerns by philosophical contemplation, while some Christians found value in mortifying the flesh, thereby turning their thoughts to the immortality of the soul. Medieval Islamic culture elaborated the Greek ideal of the healthy, happy aristocrat, and cultivated royal doctors famous for entertaining stories and jokes. It also promoted musicians, all to preserve the health of noble patrons. Medieval scholastic philosophers, rather surprisingly, took up another Islamic pursuit, alchemy. From the thirteenth century the Pope, who ideally ruled for life, patronized Christian alchemists. They argued that the recovery of knowledge about the philosophers' stone (which was known to the ancients) would not only make one rich, but return the body to its pristine state before original sin brought disease and the ravages of old age into the world.

The rage for medical alchemy, which only grew during the Renaissance, brought into focus the importance of philosophical thinking, drawing upon the ideas of many cultures, to the development of notions about bodily health. Rationality, a peculiar obsession of the Greeks, contributed to the separation of bodily concerns from those of the spirit. Although ancient Greek physicians called themselves philosophers, they excluded from philosophical/medical consideration supernatural causes of disease as being the province of magicians, because they were anxious to define their young profession as different, and better, than that of the faith healer. Medieval Christian and Islamic physicians admitted that lack of health could be associated with sin or magic, but dismissed these factors as outside the realm of Aristotelian medical practice. The seventeenth-century thinker Descartes (1596–1650), as part of a larger mechanical philosophy, made a separation between mind and body that was total. For Descartes, and other mechanists who followed after him, the healthy body was nothing more than a well-functioning machine, soulless and subject to chemical and mechanical remedies.

Cartesian medical philosophy not only excluded religious concerns from the proper duty of the learned physician, but also made easy the postulation of ‘mental’ illnesses and ‘mental’ health as being separate from the state of the body. Vitalist views of the body and health did not fade from consideration all at once. Individualized, pastoral-style medical care of the whole person experiences periodic revivals, especially when Westerners study subcontinental and far-Eastern methods of healing. But the notion of the body as a machine emphasized the sameness of all bodies rather than their uniqueness. The remarkable growth in medical technology from the end of the eighteenth century allowed medical scientists to ‘look inside’ the normal, living body and define its typical characteristics as never before. For example, the discovery of auscultation and later the stethoscope made individual patient reports of symptoms less important than the physician's own collection of diagnostic signs. Doctors could listen to the internal sounds made by hundreds of healthy bodies and easily isolate the ‘abnormal’, leading to a kind of medical objectivity never imagined before. The modern diagnostic laboratory of today allows the isolation of ungendered, raceless, classless tissue samples from subjective judgement and, for better or worse, minimizes the patient's own assessment of his or her state of health.

Nostalgia for a lost golden age never disappears from the medical scene, of course. Nineteenth-century Romantic thinkers offered the ‘noble savage’ or the ‘primitive’ hunter-gatherer as an ideal of bodily (and sometimes of moral) health. Even today, experimental studies with animals suggest that living in a state of near-starvation the way our ancestors were forced to do would lead to longer life and greater health — as if such a life would be worth prolonging. ‘Quality of life’ considerations will always be foremost in the mind of the patient, and this is an aspect of health that technologically-based scientific medicine, almost by definition, may appear to neglect. But in the contexts of clinical trials and medical audit the profession increasingly acknowledges the importance of quality of life as a component of outcome assessment.

Faye Getz


Ackerknecht, E. H. (1982). A short history of medicine. Johns Hopkins University Press, Baltimore and London.
Bynum, C. W. (1995). The resurrection of the body in Western Christianity, 200–1336. Columbia University Press, New York.
Temkin, O. (1991). Hippocrates in a world of Pagans and Christians. Johns Hopkins University Press, Baltimore and London.

See also creation myths; illness; medicine.

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health. Efforts to attain and maintain good health have a long history. A plea for good health remained an important theme for prayers from ancient times until the present day, and was often the occasion for pilgrimages. The alleged curative powers of springs precipitated the establishment of spas where wealthy visitors came to take the waters and which may be considered the forerunners of modern health farms. Poorer people sought good health through folk medicine, using herbal remedies and techniques such as the laying-on of hands. Until the 19th cent. many believed the king's touch would cure scrofula. Caring for the sick had the blessing of the Christian churches, which urged their members both to be charitable and to care for those suffering. State intervention on a large scale in the 19th and 20th cents. aimed to promote good health amongst the population. This period also saw the development of professions and occupations, such as medicine, nursing, paramedical services, and environmental health.

The general health of people during the Middle Ages was discussed only obliquely in historical accounts and it was taken for granted that everyone suffered from the effects of seasonal food shortages. However, recent studies have suggested that larger towns were especially unhealthy because of poor sanitation and that their growth often depended on continuous migration from rural areas. Even the well-off in towns did not escape from health problems. Life expectation was relatively short. More has been recorded about the outbreak of spectacularly lethal diseases such as bubonic plague (known as the Black Death) during the mid-14th cent. and the Great Plague in 1665.

The first systematic attempt to devise indicators of the health of some groups of the population, particularly the upper and middle classes, was made by life assurance companies in the 18th cent. Measuring the size of these populations and their composition had commercial significance. Statistics about the entire population began with the establishment of the nation-wide decennial census in 1801. Censuses became increasingly sophisticated in the range of data collected. The compulsory registration of births, marriages, and deaths in 1837 made it possible to identify and analyse important overall trends in the population. For example, the government gained information about the total number of men available for national service and it was possible to start to analyse the increase in the total population.

The population of Great Britain rose from about 10 million in 1801 to over 56 million in 1991. Within these totals the distributions of age groups varied. During the 19th cent. children under the age of 15 years accounted for more than a third of the population whereas during the later 20th cent. they formed only a quarter of the total. Throughout the 19th cent. about a twentieth of the population was aged over 65 years whereas by the late 20th cent. they accounted for almost one-fifth of the total. These changes, particularly the greater life expectation, arose for several reasons: rising incomes, environmental improvements, and healthier diets.

One of the most sensitive indicators of a nation's health is that of infant mortality, the death rate of children under 1 year of age. Infant mortality rates remained well over 100 in every 1,000 live births for almost the whole of the 19th cent. By the late 20th cent. the rate had declined to about 12 in 1,000 births. Within the British Isles there were geographical variations, with the highest mortality rates in the most densely populated areas. There were differences between social class with the highest rates amongst children whose fathers were in unskilled work and the lowest amongst the children of fathers in professional occupations. Relevant factors in explaining these rates appear to have been incomes, quality and quantity of food, heating, clothing, and housing.

Public health became a matter for government intervention during the 19th cent., partly precipitated by an outbreak of cholera in 1831 whose virulence paid no respect to social class. Interventions were based on theories about the link between health, clean water supplies, and adequate sanitation. The Public Health Act of 1848 required districts with above-average death rates to have a public health board with powers to raise loans and levy rates to pay for pure water supplies, drains, and sewers. These powers were extended subsequently to all parts of the country. Advances in the biological sciences with regard to the transmission of disease and the need for high standards of hygiene were incorporated into legislation after the middle of the 19th cent. Then, as now, such developments were controversial. Nineteenth-cent. debates about compulsory vaccination, immunization, and drug-taking can be compared with modern debates about fluoridation and smoking.

Efforts to improve the health of the school population began at the end of the 19th cent. They started with ‘drill’ and evolved later into physical education, emphasizing gymnastics, swimming, athletics, and games. From the end of the 19th cent., the curriculum for girls included cookery, later domestic science, and more recently home economics, whose purposes included imparting some basic knowledge of personal and household hygiene as well as dietary information. With the establishment of the national curriculum in the early 1990s, health studies became an optional subject for all.

During the 19th cent. there was an expansion in medical knowledge and in the variety and range of occupations devoted to the care of the sick. In the 20th cent. the care of the sick became increasingly likely to take place in hospital rather than at home. The establishment of the welfare state, in particular the National Health Service in 1948, indicated the political will to find resources for public health.

Evidence indicates that the health of the population has improved through the control of infectious diseases, public health provisions, such as clean water and sanitation, and effective legislation about the quality of food and drink. There has also been an expansion of medical services. A major controversy about the evidence of improved health of the general population is whether medical interventions, including public health measures, contributed as much as adequate nutrition, shelter, clothing, and heating.

Ian John Ernest Keil


McKeown, T. , The Rise of Modern Population (1976);
Oddy, D. J. , ‘The Health of the People’, in Barker, T., and Drake, M. (eds.), Population and Society in Britain 1850–1980 (1982);
Porter, R. , Disease, Medicine and Society in England (2nd edn. 1993);
Smith, F. B. , The People's Health, 1830–1910 (1979).

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For many years, health was defined merely as the absence of disease. However, it has become clear that health is an active process that depends on the supportive interaction of all the body's systems. Reflecting this concept, the World Health Organization (WHO) defines health as "the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Many groups, such as the American Public Health Association, Worksite Health Promotion, and the National Wellness Association, have expanded the concept of health further to encompass wellness: the spiritual, social, mental, physical, and occupational needs for one to live life to the fullest.

In either sense, health is a state of action that includes prevention, care, and individual responsibility to achieve optimal health. The U.S. Department of Health and Human Services (HHS), in Healthy People 2010, divides the ten leading factors affecting health into two major themes. The first, lifestyle challenges, includes physical activity, avoidance of excess weight and obesity, abstinence from tobacco use or substance abuse, and responsible sexual behavior. The second, system enhancement challenges, include mental health, freedom from injury and violence, good environmental quality, immunization, and equal access to health care.


The state of health reflects the body's homeostasis, its attempt to maintain a relatively stable internal environment while confronted with changes in the external environment. One's ability to handle stress depends on the body's success in maintaining or returning to homeostasis. Failure to do so can result in abnormal function and disease.

Homeostasis involves negative feedback systems. The analogy to home heating and cooling systems is often made. When a house falls below a certain temperature, the system turns on to heat the house back to the set level. If it gets too warm, another system effects a change to cool the home off. Similarly, the human body senses changes from ideal conditions in variables, such as blood glucose , dehydration, blood calcium, carbon dioxide, heart rate, breathing rate, and fat deposition. The body also detects the presence of pathogens that alter homeostasis. When such factors disturb homeostasis, the body releases substances such as hormones , neurotransmitters , and antibodies to return conditions to normal.

Why is health important? The WHO states that it is fundamental to world peace and security as political strife can stem from inadequate food, medicine, or other resources. For the United States and other industrialized nations, the large increase in the older population calls for strategies to increase the number of quality years as people age. Living longer is not a positive goal if it means living longer with disease. HHS has made this one of two major goals in Healthy People 2010. The other is to eliminate disparities in health based on race or ethnicity. Too many segments of American society are not reaping the benefits from advances in medicine, technology, and health care.

The National Institutes of Health (NIH) is one of eight health agencies of the U.S. Public Health Service. The NIH was founded in 1887 with the goal to acquire new knowledge to help prevent, detect, diagnose, and treat diseases and disabilities. As one of the world's fore-most medical research centers, the NIH conducts research, supports research elsewhere, helps train researchers, and fosters communication about medical and health sciences information.

Individual choices are important to health outcomes. Preventive medicine includes stress reduction, good nutrition, exercise, wearing seat belts and helmets, and having routine dental and physical screenings (for cholesterol level and blood pressure, for example). As science progresses in genetic engineering, important choices will be made about changing genes, thus altering the inheritance of many diseases.

see also Alcohol and Health; Cardiovascular Diseases; Disease; Environmental Health; History of Medicine; Homeostasis; Public Health Careers; Sexually Transmitted Diseases; Smoking and Health

Karen E. Jensen


Donatelle, Rebecca J. Health: The Basics. Boston: Allyn and Bacon, 2001.

National Institutes of Health. <>.

World Health Organization. <http://www.who>.

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197. Health

See also 122. DISEASE and ILLNESS .

analgesia, analgesy
the absence of pain. analgesic, analgetic, adj.
Medicine. diagnosis of a condition on the basis of its resemblance to other conditions.
the use of friction, especially rubbing, in therapy or as a remedy.
anesthesia, anaesthesia, anesthesis, anaesthesis
the absence of physical sensation. anesthesiologist, anaesthesiologist, anaesthetist, n. anesthetic, anaesthetic, n., adj.
the destruction of microorganisms that cause infection. antiseptic, adj.
the process of preventing the growth or spread of bacteria. bacteriostat, n. bacteriostatic, adj.
cachexia, cachexy
general physical or mental poor health; weakness or malnutrition.
Medicine. an unhealthy condition, especially an imbalance of physiologic or constitutional elements, often of the blood. Cf. eucrasia. dyscrasic, dyscratic, adj.
the formation of scar tissue as part of the healing process. epulotic, adj.
1. Medicine. a normal state of health; good health.
2. physical well-being. Cf. dyscrasia. eucrasic, eucratic, adj.
eupepsia, eupepsy
a condition of good digestion. eupeptic, adj.
evectics, euectics
the theory of the achievement and maintenance of good health. evectic, euectic, adj.
any substance for killing germs, especially bacteria. germicidal, adj.
hygeist, hygieist
a hygienist.
Rare. hygienics. Also called hygiantics.
1. the branch of medical science that studies health and its preservation; hygiene.
2. a system of principles for promoting health. hygienist, n. hygienic, adj.
hygieology, hygiology
Rare. the science of hygiene; hygienics.
hypochondriacism, hypochondriasis
1. Psychiatry. an abnormal state characterized by emotional depression and imagined ill health, often accompanied by symptoms untraceable to any organic disease.
2. excessive concern and conversation about ones health. Also called hypochondria, nosomania . hypochondriac, n. hypochondriacal, adj.
Obsolete, a state of good health; strength.
the gradual process of a disease, ending in the recovery of the patient. See also 72. CELLS . lyterian, lytic, adj.
protection from or prevention of disease. prophylactic, adj.
Rare. the state or condition of being curable; susceptibility to remedy. sanable, adj.
Rare. 1. a treatise on health.
2. the science of attaining and maintaining good health. soteriological, adj.
preventive or preservative treatment or measures; prophylaxis. See also 145. ETHICS .
the state or quality of having good muscular tone or tension. tonic, adj.
an abnormal fear of vaccines and vaccination. Also called vaccinophobia.
1. a condition of poor health.
2. a state of being concerned with health, often excessively.
3. invalidism. valetudinarian, n., adj.

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Health is a measure of quality of life that is difficult to define and measure. In the 1940s, the World Health Organization (WHO) defined health as a "state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." At the first International Conference on Health Promotion in Ottawa, Canada (1986), the Ottawa Charter for Health Promotion built on the WHO's concept and further defined health as "a resource for everyday life ... a positive concept emphasizing social and personal resources, as well as physical capabilities." Good health enables one to function independently within a changing environment.

see also Health Communication; Health Education; Health Promotion; Healthy People 2000 Report.

Delores C. S. James


World Health Organization (1948). Official Records of the World Health Organization, No 2: Proceedings and Final Acts of the International Health Conference Held in New York from 19 June to 22 July 1946. New York: United Nations, WHO Interim Commission.

Internet Resource

World Health Organization (1986). Ottawa Charter for Health Promotion. Available from <>

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320. Health

  1. agate symbolizes health; supposed to relieve snake and scorpion bites. [Class. and Medieval Legend: Leach, 27]
  2. Asclepius cup symbolizes well-being. [Gk. Myth.: Jobes, 397]
  3. Carna goddess of physical fitness. [Rom. Myth.: Leach, 192]
  4. Damia goddess of health. [Gk. Myth.: Jobes, 409]
  5. Hygeia goddess of health; daughter and personification of Asclepius. [Gk. Myth.: Kravitz, 123]
  6. Hygeias cup symbol of fertility and fitness. [Gk. Myth.: Jobes, 396397]

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health / hel[unvoicedth]/ • n. the state of being free from illness or injury: he was restored to health | [as adj.] a health risk. ∎  a person's mental or physical condition: bad health forced him to retire. ∎ fig. soundness, esp. financial or moral: a standard for measuring the financial health of a company. ∎  used to express friendly feelings toward one's companions before drinking.

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health soundness of body, mind, or spirit OE.; toast drunk to a person's welfare XVI. OE. hǣlð = OHG. heilida :- WGmc. *χailiþa, f. Gmc. *χailaz WHOLE; see -TH1.
Hence healthful salubrious XIV; having good health XVI (superseded in this sense by healthy XVI).

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healthhealth, stealth, wealth •commonwealth •filth, tilth •coolth

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