Last summer, when the country was trying to get its head around the necessity of health care reform and how best to tackle the unrelenting growth of health costs, the New York Times published a fascinating article that urged us to ask some equally big questions: What constitutes health and how should we define it?
The article was called "To Overhaul the System, ‘Health' Needs Redefining," and its author, H. Gilbert Welch, professor of medicine at Dartmouth's Institute for Health Policy and Clinical Practice, made some startling home truths.
"If health is the absence of abnormality," he argued, pointing to several good examples in American medicine, then "the only way to know you are healthy is to become a customer. But healthy people aren't great customers; they're like the people who pay off their entire credit card balance each month. The money is in those in whom an abnormality can be found. The medical-industrial complex has made that relatively easy to do."
Dr. Welch, who for years worked as an insider in the system, went on to discuss how easy it is to create finer and more-subtle distinctions that result in skyrocketing costs for the country while doing little to improve our national health. The medical-industrial complex he referenced "develops diagnostic technologies able to find smaller and smaller abnormalities."
"And the medical-industrial complex has another way to find more" of these, he continued: "It simply narrows the definition of normal. Take blood pressure. In the past, relatively few were said to have abnormal blood pressure. Now a normal blood pressure is said to be below 120/80. This means that well over half the adult population of the United States is abnormal. The same is true for cholesterol. And although it involves a smaller portion of the population, narrower definitions of normal are expanding the number of people said to have diabetes and osteoporosis. So more and more of us are treated for these conditions."
"Finding more abnormalities has been a great strategy for our industry," Dr. Welch acknowledged. "But it has been a disaster for health-care costs."
It has also, he noted, done subtle but extensive damage to our understanding of what health really is. If we view health as the absence of abnormality, then we're setting it up as an ideal that, by definition, fewer and fewer Americans can attain. For starters, such a definition is too broad—"we all harbor abnormalities," he notes, or can easily be represented as doing so. But ideals do not always encourage better practice; they can also be punitive and exclusionary, with judgments that can rapidly acquire a moral underpinning.
The editors of an important new book called Against Health: How Health Became the New Morality characterize such thinking as follows: "You see someone smoking a cigarette and say, ‘Smoking is bad for your health,' when what you mean is, ‘You are a bad person because you smoke.' You encounter someone whose body size you deem excessive, and say, ‘Obesity is bad for your health,' when what you mean is, ‘You are lazy, unsightly, or weak of will.' You see a woman bottle-feeding an infant and say, ‘Breastfeeding is better for that child's health,' when what you mean is that the woman must be a bad parent."
Out of concern for the way such judgments and accusations structure and increasingly inform debates about public health, the editors of the book, Jonathan Metzl and Anna Kirkland (both on the faculty at the University of Michigan) decided to organize a conference on the topic, which they gave the startling, counterintuitive title Against Health. It was also from shared concern about the way American medicine and psychiatry are systematically shrinking the category of normalcy in mental and physical health that I decided to contribute an essay to the collection, addressing how Passive-Aggressive Personality Disorder (PAPD) went from being a military concern about "willful incompetence" at the end of World War II to being, post-1952 (the publication date of DSM-I), a bona fide mental disorder which by 1966 accounted for more than 3 percent of hospitalized patients in public mental institutions and over 9 percent—yes, 9 percent!—of outpatient clinic patients that year.
Yet even after the American Psychiatric Association published the revised third edition of the DSM in 1987, it continued to assert, in this global "bible" of mental health, that the disorder could be recognized by such routine traits as "fail[ing] to do the laundry or to stock the kitchen with food because of procrastination and dawdling" (DSM-IIIR 301.84). Indeed, even though PAPD was put in the Appendix to DSM-IV in 1994, it was not eliminated from the manual. There are, in addition, concerted efforts by leading psychiatrists to restore it to the main body, where they argue vociferously that it still belongs.
Excellent essays in the collection focus on "risky bigness" and "fat panic"; pharmaceutical propaganda; how science is used arbitrarily in discussions of global health; how OCD became a mental health pandemic just years (and millions of dollars of drug-related marketing) after its formal recognition; and how definitions of sexual normalcy are constantly being rethought and updated.
Still, why "Against Health"?, Metzl asks rhetorically in his introduction, detailing a frequent question that friends, relatives, colleagues, and patients ask him. "Shouldn't we be for health?" In principle, yes, of course. No one in any of the public or mental health professions would want anything less for their patients. But, like Dr. Welch's article in the New York Times, which argues that "health" itself needs redefining if we're to capture its essence more effectively and meaningfully, Metzl asks us carefully to consider where the term normally appears and how it's most-often used. When we pick up a copy of Health, Healthy Living, or Men's Health and Women's Health, he notes, isn't it the case that "these publications share the common assumption that health is intimately connected to, and ultimately even defined by, a person's appearance" (2)?
When we're bombarded by spam email and TV ads waxing ecstatic about "sexual health," too, isn't it also the case that the products being sold are pharmaceuticals for "erectile dysfunction" that can badly affect the sight of the men who take them? For sure, they aren't infomercials on how popular, low-cost, and highly nutritious cereals like oatmeal also happen to be highly effective aphrodisiacs (as people have known for centuries). ("Honey, let's have porridge again for breakfast.")
If health is the absence of abnormality, as is increasingly the case today, then we should all be seriously concerned about systematic efforts to expand the range of medical and psychiatric "abnormalities," which squeeze out attention to serious and chronic medical conditions. Such efforts to rebrand "health" make costs resemble a runaway train that will soon do lasting damage to our national budget and deficit. If we're serious about reining in costs, we need to argue against the redefinition of normalcy. At stake, of course, is nothing less than our collective well-being.
References
Jonathan M. Metzl and Anna Kirkland (eds.), Against Health: How Health Became the New Morality (New York: New York University Press, November 2010).
H. Gilbert Welch, M.D., "To Overhaul the System, ‘Health' Needs Redefining." New York Times (July 27, 2009).
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