ACADEMIA Letters

An Amplified Concept of Health

Afonso Carlos Neves, Universidade Federal de São Paulo (UNIFESP)

In 1948 The World Health Organization (WHO) elaborated a Concept of Health as “a state
of complete physical, mental and social well-being and not merely the absence of disease or
infirmity.”1
Since that affirmation, there are social factors inserted into such a concept. Until then,
health was considered under the ancient phrase of the Roman poet Juvenal mens sana in cor-
pore sano,2 with some other affirmations as that one of Leriche in the 1930s, “health is life
lived in the silence of the organs.”3 By the way, the word ‘silence’ was appropriated to the
context of totalitarian governments in those days. However, we are not sure of the correlation
between the affirmation and the repressive condition.
After World War II, it was necessary to promote a politics of ‘welfare’ to people who
suffered more under that conflict. So did the countries that had more losings under the War.
In this line, WHO elaborated a concept of health as a kind of ‘well-being,’ introducing the
social factor in health. Before that, health was just individual. With the social condition, we
can perceive that collectivity crosses over individuals, and individuals cross over collectivity.
That social vision benefits several individuals and communities beyond selfish thinking about
health.
Following the WHO definition, we can see that physical well-being corresponds to an
‘objective’ process. On the other hand, mental well-being is related to a ‘subjective’ process.
It is essential to understand the use of these two words, ‘objective’ and ‘subjective.’ In the last
decades of the twentieth century, ‘objective’ was more and more valorized, and the opposite
1
WHO at https://www.who.int/about/governance/constitution accessed on Oct 28, 2021, 21:00 h.
2
Juvenal Sature Satura X https://la.wikisource.org/wiki/Saturae_(Iuvenalis,_Bucheler)/Liber_IV/Satura_X ac-
cessed on Oct 29, 2021, 22 h.
3
Georges Canguilhem. O normal e o Patológico. 6ª Edição. Editora Forense Universitária. Rio de Janeiro e
São Paulo, 2009 (1966), p. 205.

Academia Letters, November 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0

Corresponding Author: Afonso Carlos Neves, afonsocnn@gmail.com

Citation: Neves, A.C. (2021). An Amplified Concept of Health. Academia Letters, Article 3872.
https://doi.org/10.20935/AL3872.

1
happened to ‘subjective’. The word objective is related to ‘object’ and subjective to ‘subject’.
So, society became very pragmatic, and a kind of ‘objectification’ of human being occurred
together with dehumanization in medicine.
So, we intend to use those words, objective and subjective related to interobjective and
intersubjective to better understand the amplified concept of health.
In this line of thinking, social well-being is correlated to an interobjective process. Under
the pandemic situation, it became easier to understand the social condition of health when
people must use masks or be vaccinated. As a consensual example, the signs of traffics are
necessary to promote interobjective social well-being. So, the interobjective well-being is
established by social rules that conditionate mutual respect.
In the WHO Ottawa Conference in 1986, it was proposed that health promotion could
include cultural factors in that well-being. That Conference was a response to growing ex-
pectations for a new public health movement around the world.4 Cultural and environmental
aspects were focused.
Because of this, we think that it is possible to include a fourth component of health, the
cultural component. That component could include all factors that compound the Culture
of different people, such as artistic characteristics, ludic factors, community traditions, re-
ligiosity, spirituality. All those cultural factors can influence positive or harmful physical,
mental, and social health. Therefore, that cultural part of health can be characterized as an
‘intersubjective process.’
For the construction of a chart with these four components of health, we did a table with
two columns and two lines. Each column corresponds to ‘interior’ and ‘exterior’ aspects of
the human being; each line is correlated to individual and collective aspects. That chart is
exposed ahead.
We can see that mental health is related to a subjective process. The word ‘subjective’
is derived from ‘subject,’ different from objective physical health. So, to understand some
conditions of mental health, we must hear the person talking about subjective thoughts and
feelings.
The intersubjectivity present in the cultural factor relates to values, symbols, and other
characteristics of the collective unconsciousness common to a community. Like the other an-
imal species, we need to eat, drink, sleep and reproduce. However, for the human being, each
of these factors needs to be correlated to cultural conditions. And those cultural conditions
can even mean refusing those practices. Until we know, the human being is the only animal
species that can consciously refuse to act even compelled by instinct.
In the text ‘Incorporating “Culture” Within a Culture of Health,’ the authors Ruiz and
4
WHO - Ottawa Charter for Health Promotion, 1986. Cultural and environmental aspects were focused.

Academia Letters, November 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0

Corresponding Author: Afonso Carlos Neves, afonsocnn@gmail.com

Citation: Neves, A.C. (2021). An Amplified Concept of Health. Academia Letters, Article 3872.
https://doi.org/10.20935/AL3872.

2
Devine explain that “the pathway to greater equity and better health outcomes for individuals
in America of all cultures starts with recognizing that people from every background have
contributions to make”. So, when people are linked to the cultural values of their communities,
individuals and community are in better conditions of health. So, we can say that this is a kind
of ‘Culture of Health’, and nowadays it must be built that Culture. Today that is a growing
part of the nonwhite population in America with its own cultural characteristics that can enrich
their health. It can be seen, for example, in the Indian or Hispanic population.5 So, as the title
of that text says, incorporating Culture can be a step ahead in an Amplified Concept of Health.
With the word ‘amplified,’ we mean health beyond the WHO concept or even the interesting
biopsychosocial concept proposed by George Engel.6
Following these ideas, we must be careful not to have a reductionist attitude and reduce
each different condition to the objective physical well-being and disease. In that way, we could
think that every adverse condition, mental, social, cultural, could be solved with pills as the
physical problems of health, although sometimes it can be useful for several conditions.
It is possible to add a fifth factor, ‘environmental well-being’, as an intersection of all the
other factors. It is possible to insert here categories related to the natural environment or the
environmental conditions constructed by people. This fifth condition is nowadays growing
in importance in front of the global environmental situation. For example, we can see grow-
ing dramatic conditions in the opposite side of well-being from ecological damage that can
compromise each aspect of health.
One thing that has been a focus of critical comments about the WHO concept of health is
the word “complete” because it seems utopic and unattainable. However, it is possible to see
that affirmation by the meaning that it can be an aim to be achieved. So, all the effort can have
a proper direction, over which people can build roads to better well-being. We must see that
all that concept is about health and not about disease or infirmity. It can be useful to insert a
discussion about ‘disease’ as some counterpart to health as follows.
Other aspects of adding to this discussion are the words disease, illness, and sickness.
Today, we still use to teach in medical school an ancient phrase: “there is no disease but the
patient”. By the way, there are different meanings for three words that are sometimes used as
synonyms: disease, illness, and sickness. Mainly in the Canadian Health System, the differ-
ence among those words is reinforced. ‘Disease’ is the condition diagnosed by conventional
5
John M. Ruiz and Diana Yazzie Devine. Incorporating “Culture” Within a Culture of Health. In Culture
of Health in Practice: Innovations in Research, Community Engagement, and Action. Organized by Alonzo L.
Plough. Oxford University Press, 2020, pp. 13-24.
6
George L. Engel. The Need for a New Medical Model: a Challenge for Biomedicine. Science, 1977, 196:129-
36.

Academia Letters, November 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0

Corresponding Author: Afonso Carlos Neves, afonsocnn@gmail.com

Citation: Neves, A.C. (2021). An Amplified Concept of Health. Academia Letters, Article 3872.
https://doi.org/10.20935/AL3872.

3
medicine. ‘Illness’ is how the patient lives and sees that health condition, therefore is the
individual health impression. ‘Sickness’ is the collective condition established by a commu-
nity; so, some determined disease can be named or perceived by that community differently
from conventional medicine. We can observe such peculiarities, for example, in indigenous
communities and their traditional practices about health and infirmities. As we can see by
those conceptions, illness and sickness are more appropriately related to subjective or inter-
subjective aspects of health.7 Together with all those ideas, the ‘patient-centered medicine’ in
Canada was established where an amplified concept of health is applied.8 In a nonexclusive
way of thinking, patient-centered medicine can work together with disease-centered medicine.
Similarly, Narrative Based Medicine and Evidence-Based Medicine can complement each
other. Evidence-Based medicine has an interesting rule sometimes not remembered by pro-
fessionals: ‘to respect the values and cultural aspects of patients.’ This condition is where
Narrative Medicine can combine with Evidence-Based Medicine. We can say that Narrative
Medicine can be situated in the intersubjective cultural component of health. It is also situated
in a space between patient life stories and the conventional clinical history, or anamnesis.
By all those considerations, the binomial health-disease can be better understood under
an amplified concept of health. As examples of those conditions, authors referred to cases
that could be framed in that ‘amplified’ model, as we have also seen similar situations in our
own experience.

7
AFMC Primer on Population Health, Concepts of Health and Illness. Disposable at https://phprimer.afmc.
ca/en/part-i/chapter-1/ accessed on Oct 30, 2021, 17:00 h.
8
Moira Stewart at al. Patient-centered Medicine, Transforming the Clinical Method. Third Edition, Radcliff
Publishing, London, New York, 2014.

Academia Letters, November 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0

Corresponding Author: Afonso Carlos Neves, afonsocnn@gmail.com

Citation: Neves, A.C. (2021). An Amplified Concept of Health. Academia Letters, Article 3872.
https://doi.org/10.20935/AL3872.

4
Academia Letters, November 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0

Corresponding Author: Afonso Carlos Neves, afonsocnn@gmail.com

Citation: Neves, A.C. (2021). An Amplified Concept of Health. Academia Letters, Article 3872.
https://doi.org/10.20935/AL3872.