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  Health and Sickness in Medicine and Ecology
  

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By: Wolfgang Schad
(Revised version of a talk given at an academic discourse at Witten/Herdecke University on 29 Nov. 1997. Original title: Gesundheit und Krankheit in Medizin und Oekologie. Der Merkurstab 1998; 51:193-7. English by A. R. Meuss, FIL, MTA)

Anyone who is not a member of the medical profession is most likely to come in contact with medicine when in need of treatment. When I was not limiting myself to being a passive "patient" but trying to take an intelligent interest in the treatment I was given, I found myself greatly surprised one day. The medical staff, who I had always thought knew exactly when I was either sick or healthy, admitted, as I got to know them better and made friends with them, that they did not in fact know what "sick" and "healthy" actually meant. The Health Department should thus really be called the "Sickness Department" and the Minister of Health "Minister of Sickness." Oddly enough this is considered discreditable and so the term is avoided. On the other hand we do speak of "sickness" and not "health" insurance.

Finding myself an involved citizen I thus began to consider this matter of health and sickness and study Gerhard Kienle's book on drug safety.(1) In it I found a definition of health that is used the world over, part of World Health Organization's (WHO) 1946 declaration to the effect that health is a state of complete physical, spiritual and social well-being and not just the absence of sickness and infirmity. Enjoyment of the best possible state of health that can be achieved is one of the basic human rights independent of race, religion, political views and economic and social conditions. The first words were rephrased in 1957 to say that health is the state of complete physical, mental and social well-being....

Health, as defined above, is thus actually called a basic right. This claim can never be met, however, for it is an illusion to think that life can be free from fear.(2) The knowledge that one must die is something only human beings can have, and it means we can never be wholly at ease, for even suppression of this, the only certainty concerning our future, does not take this knowledge away from us.(3,4) Kienle wrote:

"If the WHO definition had total validity, heavy labor, the struggle to gain knowledge and even the adoption of non-opportunist views would be forms of sickness."(1)

The WHO definition does not hold water. Parson therefore sought to link the idea of health with the concept of personal values: "The sociological definition of bodily health is as a state of optimum ability to perform tasks that are considered to be of value."(5)

What is left open, according to Kienle, is "who determines the value and how we should consider someone who differs greatly from his social environment in his setting of values." Asocial individuals may accept and represent values that deprive them of their basis for existence. "Parson's definition gets even more problematical when we consider people who are drug-dependent and for whom drug consumption coincides with their concept of life."

Health and sickness have been considered from the 6th century B.C., starting in ancient Greece, with Alcmaion, Democritus, Plato, Aristotle, Hippocrates and Galen giving profound thought, often at a high level, to the philosophical discussions.(6) Alcmaion's isonomia (balance of forces) and Hippocrates' eucrasia (balance of humors) were not adequate, however, for life is not the attainment of final resting balances (a characteristic of dead systems) but lies in the active development of tensions that are not in balance. In modern medicine people know about hygiodynamics, with constant alternation between autonomous recovery and heteronomous performance demands.(7) The diagnostic definition of health and sickness thus continues to be uncertain to this day - especially if one reads in Nietzsche's Joyous Wisdom:

The popular moral formula in medicine (originating with Ariston of Chios) that 'Virtue is the soul's health' should at the least be changed to 'your virtue is your soul's health' to be useful. For health does not exist as such, and all attempts to define something in this way have failed miserably. It needs your aims, your horizons, your energies, your drives, your mistakes and above all the ideals and phantasms in your soul to determine the meaning of health that relates to your own body. There are thus countless states of health relating to individual bodies.(8)

This gives health - and sickness - a highly individual aspect. It is not possible to make generalizations in this field, i.e. to make a definition. When the house surgeon says to a nurse: "Go and see if the appendix in room N is alright,” this is partly appropriate and partly a generalization that is not appropriate.

This ambivalence goes right back to antiquity.(9) Is sickness a type or is it a unique, not exchangeable human being who is sick? Plato and the School of Cnidos knew only of diseases, with the patient merely an individual representative of these, in this case an appendicitis. Hippocrates and the School of Kos on the other hand knew only sick people; the physician's concern is directed to them and not merely an impersonal idea. Which, then, is the essential reality, the sickness or the sick individual? Put in this way, the question challenges us to decide between Platonism and Aristotelianism. No decision has been reached in 21/2 thousand years.

Further study of this fundamental question also shows that it is not possible to arrive at a definitive answer because human beings exist at many levels and therefore with many different meanings, also in this case. It is possible, however, to organize the material and gain an overview over the multifarious aspects that are emerging. If "healthy" has to do with intactness or integrity, and "unhealthy" with that intactness or integrity being impaired, a live-saving amputation affects the integrity of the physical totality of the body but serves to restore health to the functional vital context of that body. Optimum physiological health does not necessarily also mean high level of mental quality. In 20 years of work in teacher training, I have found, to my surprise, that students involved in high performance sports, people bursting with health, as we say, did with above average frequency show a decided lack of mental flexibility, which also applied, for instance, to the delicate empathy needed for the mental states of children. They might have made good sports teachers, but even so found the work of a class teacher, with its many different aspects, to be too much for them. On the other hand great mental agility in gifted people with a very good education could only too easily go hand in hand with having too good an opinion of oneself. This is the individual with considerable charisma who if one looks closer produces disappointingly few new ideas. So, to go down the scale again, - mental productivity - a rich inner life

- physiological resilience

- and physical integrity

are four different qualities, indeed dimensions, of health that cannot be considered equal. Plato rated a healthy inner life higher than physical health (Politeia 407-412). He felt that physical health was the physician's responsibility, mental health the philosopher's, with the body but the soul's prison, and true health gained only when it is liberated at death. Because of this, Socrates said in his final words to Crito: "...we owe Asclepius a cockerel; make that payment and do not fail to do so" (Phaidon 118a). A similar view was held in medieval Christianity, where the idea of sanitas pemiciosa (harmful health) was also known.(6)

English-speaking people still distinguish between sickness, or illness, and disease today.(9) Illness is more the subjective suffering of a person and may cause someone to go to their doctor even if there are no objective symptoms or signs. Disease refers to physical impairment and may also exist if the individual feels in good health.

As we have said, however, there are more layers to this than the dualistic division in two. In the field of geriatrics the question we are considering becomes more acute because the question is: What should be considered healthy or pathological when someone has reached a high old age? With physical involution (osteoporosis, desiccation, etc.) we can no longer speak of physical integrity. Physiological functions (digestion, wound healing, etc.) are limited. Mental presence decreases (short-term memory with loss of cerebral function). The dignity of very old people always lies in their spiritual integrity, even if this can no longer come to expression. This part of man, which cannot be touched, remains open to the future and should thus always be called healthy. Recognition of it ensures humanity in the field of geriatrics.

All four levels, however different, do have one thing in common where usage is concerned, for we speak of people being ill or well at all of them. So there must be common basic ideas to these terms. Let me list situations where this is not the case.

Someone may feel perfectly normal subjectively, with laboratory tests giving results that are completely in normal range, and yet a tumor is beginning to develop. Is this person healthy or sick? Every day we produce cells showing cancerous degeneration which the organism identifies and normally takes action to destroy. Are we therefore ever completely healthy when we believe ourselves to be so? What is more, the genome of every individual contains proto-oncogens which are the genetic disposition to oncological disease. In all three cases there is no clear distinction between health and sickness. Nor when the opposite is the case and we are patently suffering from an infectious condition, the classic criteria of rubor, calor, and dolor are actually signs that self-healing has been activated, often resulting in greater immunity and therefore also greater health than before. Again it is not possible to make clear distinction between health and sickness, but we must speak of mutual interaction. Schipperges writes:

"Historical studies and all systematic analysis have shown that there is no such concept as health. Health is neither state nor possession nor goal."(10)

The inevitable conclusion is therefore that health and sickness cannot be distinct, identifiable entities. Both, if we are clear about it, are not diagnostic terms. This finding, the result of long discussion of a fundamental aspect of medicine, should be accepted.

If, therefore, it is not possible to define the two terms empirically, one action that may be taken would be to use them no longer as medical terms and let them continue only in everyday language. The other way would be not to use these terms for a given status quo but consider once more if there is more to them than has so far been realized. What is the immediate but unspoken assumption we make when using the words "healthy" or "sick"? What do we consider to be immanent in their meaning?

It has been my observation and hence my thesis that in the final instance they are not used as a diagnosis but a prognosis. We use the term "healthy" for an organism whose future potential is not limited prematurely. To be "sick", on the other hand, means that the future is subject to a temporary or final premature limitation. We are thus referring to an option on what the future is thought to be in the given case, never a matter of a cross section in time but anticipatory thinking: options on longitudinal sections in time relating to more than the here and now. The definition given by Murphy comes close to this:

Healthy is anything that "functions effectively and looks like doing so also in future.”(11)

Ringeling's definition inherently has the same meaning:

"Health should mean the ability to function."(12)

Ability or power are terms we use to speak of chances for the future as seen in the present.

The double aspect of health (or sickness) as momentary status and time integrative option may also be traced back to ancient Greece. Originally Asclepius and Hygieia were two distinct healer gods, and they only came to be venerated together in the 5th century B.C.(13) Asclepius, son a mortal and Apollo, was taught his healing skills by the sick centaur Chiron. He was venerated as a god but killed by Zeus when he tried to save dying people from the death that was their destiny. Hygieia was always seen as an immortal goddess symbolizing health as the art of living and a sensible way of life - strong, eternally young life.(13) Asclepius, seen as a serious, bearded older man, gave help in acute need. Hygieia, a young, vital female figure, represented the health that gave potential for the future. Putting it in a nutshell we might say: Asclepius represented acute medicine, Hygieia preventive medicine, with the former concerned with the momentary status and the latter with ensuring the future.

The images from mythology are helpful but no longer able to meet our present need for understanding. Health or/and sickness are part of human life now as ever. Seeking to gain new understanding we discover their relevance to the future, such as is to be expected in the given case. The meanings of "healthy" and "sick" thus relate to the open opportunity of a greater or lesser future element and to the partial uncertainty inherent in any future.

A methodological aspect may be mentioned here. Kant distinguished between intellect and reason.(14,15) The intellect works with defined concepts. Kant used the term "reason" for the ability to perceive ideas. Ideas cannot be sharply defined. The meanings of "health" and "sickness" cannot be defined in a static way because of their connection with the future, which also means they are not so much concepts but rather ideas by nature. Compared to concepts, ideas are not firmly established but capable of growth, of being molded, adapted to an ever-changing reality. Concepts meet the needs of formal thinking but also tend to suffer from limited agreement with reality.

Let us therefore stay with the ideal character of our theme. The question immediately arises as to in how far options on the future can be made more reliable. One obvious answer would be by giving full consideration to the individual's past biography. This provides information on previous illnesses and recoveries; combined with the current status it gives us more of a picture of the option on the future. Here we come to an important point. Professional medical assessment of "healthy" and "sick" arises through time integration relating to the patient's individual biography on the basis of previous history, diagiwsis and prognosis. The terms we are interested in thus refer to assessing the time dimension by integration beyond the present status. Based on the status quo only they are open to question.

The capacity for time integration lies not only in the conscious mind of the person making the assessment but also unconsciously in every organism. An organism is not only the functioning here-and-now but also has its evolutional past, with its genealogical genome or ontogenetic character as partial determinants. It always has potential capacity for more than has actually been brought to realization, e.g. where the capacity for regeneration is concerned. Developmental physiologists(16) refer to this second fact by saying that the prospective potential of evolution is always greater than the prospective significance (i.e. reaching the state which so far has been normal). In its present determinants and present generative capacity every organism thus integrates its past evolution and future potential into the present itself. The interesting point for me as an evolutional biologist was that the dilemma which arises in discussing these fundamentals is resolved in thought in the field of medicine if one realizes that this dilemma is the outcome of our imperfect notion of time, considering it to be linear only, whilst it will only be possible to speak of sickness and health in a meaningful way if we achieve integration in time.

The capacity for integrative time structure is a characteristic of every organism and in this respect the characteristic of a time organization that continually makes something consecutive simultaneous, thus making it possible to have a "time body" that is neither wholly spatial nor wholly linear in time but mediates between the two, evidently taking part in both - simultaneity and consecutiveness. This new approach to the concept of health and sickness only has validity because it offers clear insight into the characteristic of life, which is its integral time capacity.

Then there is also the following. If "healthy" means to be open to the future, the "most healthy" must be something that will never have an end. This also helps us to fully understand Rudolf Steiner's words: "The spirit is always healthy." Conversely we may say: Anything which is so healthy that it will never die may always be taken to be of the spirit. Anything we take to be the body is always mortal, and thus in the terms used by Steiner also always a sickness, but it is a matter of "being ill" for the purpose of higher health. And thus sickness and mortality are also seen to have meaning in relation to the health of the spirit.

Having thus gained a basis for understanding, it is possible to look at the related discussion in the field of ecology. May we also speak of healthy and sick landscapes, or actually not? The first thing we find is that the biosphere of a landscape is also time integrative, as evident from the diaspore potential of the soil, the plant spore and seed bank which normally is richer in species and numbers than the actual plants growing there(17) Fungal, moss and club moss spores and also orchid seed, for instance, may lie dormant for many decades until specific microclimatic conditions stimulate germination. Those spores and seeds thus permanently hold a piece of the biotope's past history and also future potential in the "diaspore rain” that is continually coming in from other plant communities.(18) Something we tend to think of only in terms of linear succession is at the same time also simultaneous.

The visible plant cover of a biotope is not generally a neatly defined plant community; it is time integrative, containing remnants of earlier and islands that hold the potential for future communities. At least three successive plant communities thus interpenetrate, with simultaneity in space.(18)

This means that planning should be as time integrative as possible, i.e. long-term, in caring for landscapes and in geomedicine. It is as important to take stock of existing vegetation as to assess the sustainability of proposed measures. The sustainability concept in particular should be given high priority, for it affects the option on an unlimited future and allows one to assess how healthy or sick the landscape is at present. This is an absolute requirement for the future co-existence of a highly technological society and its natural foundations. The Brundtland Report(19) and the Rio Conference(20) led to the concept of "sustainable development" becoming widely accepted in ecopolitical discussions.(21) Here reason added to intellectual understanding by thinking of a more long-term future, i.e. health regained in the sense we have been considering.

What does this achieve? The insight that the idea of health and that of sickness, fruitful for time out of mind, cannot be defined as status but only continue to have meaning in scientific thinking and practical application in terms of their integrative temporalization. It is not what is but what is evolving that may be found in the real world. Let me conclude with a verse quoted at the beginning of a medical book published about 100 years ago:

You say the greatest boon on earth is to be well.

I must deny this, for the greatest boon of all is to get well.(22)

Wolfgang Schad, PhD, Witten/Herdecke University, Stockumer Sir. 10, D-58448 Witten, Germany References: 1 Kienie G. Arzneimittelsicherheit und Gesellschaft. Eine kritische Untersuchung. Stuttgart: Schattauer 1974.

2 Deich F. Was ist Gesundheit? Dtsch Aerzteblatt 1957; 42:493-500.

3 Danek K. What do we fight for? Health Education Journal 1965; 24:130-4.

4 Hersch J. Sante: L/utopie d'une definition. Schweiz Aerztezeitung 1981; 62:1531-2.

5 Mitscherlich A et al. (Hrsg.). Der Kranke in der modernen Gesellscliaft. Berlin 1967.

6 Spijk P van. Definition und Beschreibung der Gesundheit. Ein medizinhistorischer Ueberblick. Schriftenreihe der Schweizer Gesellschaft ruer Gesundheispolitik Nr. 22. Muri BE/Schweiz 1991.

7 Hildebrandt G. Gesundheit, Leistungsfaehigkeit und rhythmische Ordnung. Therapeutikon 1991; 6: 628-38.

8 Nietzsche F. Joi/ous Wisdom Tr. 1910. (German original: Froehliche Wissenschaft 1882).

9 Gross R. Gesundheit und Krankheit in ihren verschiedenen Aspekten. Dtsch Aerzteblatt 1980; 21:1397-1406.

10 Schipperges H. in Ringeling.12

11 Murphy in Gross,91397,1406.

12 Ringeling H. Ganzheit und Gesundheit. Biblisches Menschenbild und medizinische Ethik. Schiveiz Aerztezeitung 1982; 51:2321-8.

13 Paulys Real-Enzyklopaedie der classischen Alter tumswissenscliaft. Stuttgart: Metzler 1896.

14 Kant I. Critique of Pure Reason (1781-6). Tr. N. Kemp Smith 1933.

15 Steiner R. Tlie Science of Knowing, chapter on intellect and reason. Tr. W. Lindeman. Spring Valley: Mercury Press 1988.

16 Seidel F. Entwicklungsphysiologie der Tiere Bd 1. Berlin 1972.

17 Dierschke H. Pflanzensoziologie. Grundlagen und Methoden. Stuttgart: Ulmer 1994.

18 Ellenberg H. Vegetation Mitteleuropas in den Alpen. Stuttgart: Ulmer 1996.

19 WCED (World Commission on Environment and Development) Our Common Future (Brundtland Report). OUP 1987.

20 UNCED (United Nations Conference on Environment and Development), Rio Conference Documents 1992.

21 Fritz P, Huber J, Levi HW. Nachhaltigkeit in naturwissenscahftlicher und sozialwissenschaftlicher Perspektive. Stuttgart: Hirzel 1995.

22 Platen M. Die neue Heilmethode Bd 1. Berlin: Deutsches Verlagshaus Bong 1900.

Other works consulted:

- Fischer-Homberger E. Geschichte der Medizin. Berlin: Springer 1977.

- Gross R, Loeffler M. Prinzipien der Medizin. Fine Uebersicht ihrer Grundlagen und Methoden. Berlin: Springer 1997.

- WHO Constitution p. 449. Geneva 1958.





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