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One Thing's Certain: Definitions of Health, Disease Are Ever Changing

Posted on: Monday, 18 July 2005, 15:00 CDT

Columnists who write about cars know a car when they see one, and I doubt that baseball columnists ever ponder "What is baseball?" But "What is health?" is a central question for many in this field.

It would be simpler if health and disease were always two separate, opposing categories divided by a bright line, with the category you fall into determined by the best and latest science.

Sometimes the divide does reflect clear-cut science: the tumor is malignant or not, for example. But what we call "healthy" and "unhealthy" is sometimes not so precise, fixed or scientific.

Yet billions of dollars ride on what we put in that box called "health." For patients, a definition can determine whether we receive treatments, whether we get access to costly services, and whether we worry about our present and future health.

Anyone who steps on the scale or measures their body mass index knows that whether you are considered obese or overweight, at a healthy weight or a dangerous one, has jiggled around lately like so much extra fat.

Or maybe you had your blood pressure checked the other day and were told you need treatment for hypertension even though your blood pressure was the same as last year when you were declared fine.

Today's drive to identify conditions that predict later disease such as weight, cholesterol levels, blood pressure readings or prostate screening scores makes the line between who needs treatment and who doesn't especially malleable. Is a blood pressure reading of 120/80 still healthy? Or, as a recent report suggests, could a top (systolic) number of 120 signal increased risk for heart disease or other health problems?

Researchers study these predictors to try to identify the risk of disease associated with various test results. But this is only the raw data and it can be ambiguous and contradictory. Translating those findings into treatment recommendations for your doctor to follow usually takes formal reviews of the data by expert committees.

A recent series in the Seattle Times concludes that pharmaceutical companies "have commandeered the process by which diseases are defined." The incentives are clear. If these companies can push down the threshold for who is hypertensive or overweight or who has bone loss that falls short of osteoporosis, it means billions more dollars in pharmaceutical sales. Millions more customers redefined as unhealthy will starting taking drugs to treat these "pre-disease" conditions and taking the risk of side effects from drugs, too.

The companies influence the definitions, the newspaper reports, by establishing close financial ties through research and other support with leading experts who become members of the prestigious panels that set disease parameters. Yes, the experts review the medical research. But, the Seattle Times series suggests, their conflicts-of-interest color their conclusions about the clinical implications of the research findings. It's a controversial series worth reading. You can find it at seattletimes.nwsource.com/news/ health/suddenlysick.

How disease is defined also helps determine which treatments insurers cover and thus who has access to costly services. A year ago, Medicare reversed itself and declared obesity was a disease not a personal weakness. That redefinition meant costly surgical treatments and other weight loss services could be covered for the older and disabled patients Medicare serves. Medicare decisions often prompt private insurers to rethink their policies as well.

Infertile couples facing tens of thousands of dollars in treatments also want insurance coverage. Is infertility a medical condition? If a married couple gets medical coverage for reproductive services, should a single woman or a lesbian couple who wants a child be covered, too? Do we call infertility a health problem for some but not all? Science can't answer that. Social factors are what define health here.

How we define health can also have political consequences or motivations. Homosexuality was once listed as a psychiatric disease in the classic psychiatric manual. When after acrimonious debate it was removed in 1973, psychiatry was proclaiming that homosexuality is not a disease.

The more widespread and threatening a health problem appears, the more likely it will capture attention and resources. That can cause a tug of war over how health is defined. A recent Harvard study sounded an alarm when it reported that more than half of Americans suffer from mental illness at some point in their lives. Some critics of the report claim that mental health problems are so broadly defined that the inevitable ups and downs of life are included.

New research helps build the scientific base for defining health but it is wise to be aware that economic, social and political factors can also affect whether you feel healthy or not.

Next week: John A. Schneider

Renie Schapiro has taught at the Yale School of Epidemiology and Public Health and at University of Wisconsin Medical School. She can be reached at renieschapiro@hotmail.com.

Copyright 2005, Journal Sentinel Inc. All rights reserved. (Note: This notice does not apply to those news items already copyrighted and received through wire services or other media.)

Source: Milwaukee Journal Sentinel

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