MSW 770

DISTICTIONS BETWEEN HEALTH, DISEASE AND ILLNESS

There has not been an absolute consensus on the definitions of health, disease, and illness, even
though these concepts are central in medicine and the health social sciences (e.g., medical
sociology, health psychology, and medical demography). These are parts of the conceptual tools
in various medical-related fields. A definition of each concept is imperative because they
constitute parts of the analytical tools in medical sociology. The lack of consensus often prevents
uniformity of interpretations and generates more polemics. One wonders why there has not been
consensus, despite the long history of medicine. The concepts are multidimensional, complex,
and often elusive. For instance, Larson (1999) observed that disagreements about the meaning of
health are common because health is imbued with political, medical, social, economic, and
spiritual components. It is subject to various conceptualisations and interpretations. While all the
concepts have their foundations in medicine, a biomedical perspective of health or disease may
not be comprehensive enough. However, a fusion of the various perspectives often presents a
complex definition like the WHO’s definition of health. This is why the debate on the definition
of health is still ongoing. That the debate continues is not a problem as refinement of definition
could lead to a better conceptualization

How Should Health be Defined?

The concept of health presents a form of ambiguity because it is multidimensional, complex, and
sometimes elusive. Notwithstanding, various scholars, apart from the definition given by the
WHO, have defined the concept. Although it is not the first definition of health, the WHO’s
definition will still be the starting point because it is relatively old and has been central to the
debate on the meaning of health. WHO (1948) defined health as a state of complete physical,
mental, and social well-being, not merely the absence of disease and infirmity. The definition is
holistic, and it presents three major interrelated components of health (see Fig. 2.1).

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 Fig. 1
Components of health

1. The physical: this is the physiological or biological component of the definition. It simply
implies the maintenance of homoeostasis. This is often used to infer a soundness of the body.
Most often, disease represents a malfunction of a part of the body system or an intrusion of
harmful organisms such as a virus or parasite. This may cause a breakdown of the individual
affected. This physiological aspect is the most important biomedical criterion in the
determination of health. For someone to be healthy, his/her biological components must be in
order. A major diagnosis procedure involves a determination of what could be wrong with any
component of the body or detection of any intrusion of any anti-body by tracing the pathways of
the disease from underlying causes to pathology in the human body system and examination of
any emerging of symptoms. Determining this may involve a series of laboratory tests or clinical
examinations. One may be certified as healthy if there is no detection of any biological hitch.
2. The social: this represents the behavioural aspect of human health. Being a member of society is
being in the network of social interaction and being able to fulfil social roles and expectations. If
an individual is not active in the social network, it represents a form of social pathology —an
abnormality, which is an infraction on the norms and values of society. The social also
incorporates the spiritual dimension. The spiritual aspect could be personal to the individual by
connecting to the world of reality and divinity. Larson (1999) observed that since the WHO’s
definition of health, medicine has treated individuals as social beings whose health is affected by
social behaviour and interaction.

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3. The mental: this indicates the psychological, emotional, and mental status of the individual.
Emotional apathy, fixation, and maladjusted personality constitute a part of the manifestation of
illness. Huber et al. (2011) observed that the mental aspect of health signifies the possession of a
“sense of coherence,” which includes the subjective faculties enhancing the comprehensibility,
manageability, and meaningfulness of any circumstances.

The WHO’s definition has been heavily criticised since it was conceived in 1946 after the
Second World War (see Callahan 1973; Bice 1976; Pannenborg 1979; Wood 1986;
Simmons 1989; Saracci 1997; Jadad and O’Grady 2008; Huber et al. 2011; Godlee 2011;
Awofeso 2012) . For instance, Awofeso (2012) observed that the definition is inflexible and
unrealistic. He claimed that the inclusion of the word “complete” in the definition makes it
unlikely for anyone to be healthy for a reasonable period of time. Godlee (2011) also noted that
the definition is absolute and therefore unachievable for most people in the world. The definition
presents an absolute ideal situation by combining the three aspects of human life. It is often
difficult, if not impossible, to gain complete contentment in all the aspects. It is observed that
since health is a goal, not only of the health care system but also individual and the society at
large, it is ideal for a body like WHO to present a realistic definition that can be operationalised
and achievable (Godlee 2011) .

In addition, Saracci (1997) also submitted that the WHO’s definition of health is problematic and
it should be reconsidered. Saracci observed that the definition equates health with happiness—
that a disruption of happiness could be regarded as a health problem. He further argued that the
WHO’s definition reflects that health is boundless. More so, Huber et al. (2011, p. 2) opined that
the WHO’s definition is problematic because it impliedly declares people with chronic diseases
and disabilities definitively ill. The definition further minimises “the role of the human capacity
to cope autonomously with life’s ever changing physical, emotional, and social challenges and to
function with fulfilment and a feeling of wellbeing with a chronic disease or disability” (Huber et
al. 2011, p. 2) . Despite several decades of criticisms, the WHO has not reviewed the definition.
The idea of a definition is to present a holistic view that is meaningful not only for individuals
but also as a (definitive) tool in scientific investigation. The idea is not to advance an operational
perfection that is unchangeable. Perhaps, there is yet a review because there has not been a more

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holistic and measurable alternative definition of health. The question is simple: are other
definitions of “health” more operational?

A New Definition of Health?

Several other scholars have proposed other definitions of health , which can be used in light of
changing global health circumstances. Some of these definitions will be critically examined;
however, the essence of examining other definitions is not to defend the WHO’s definition or to
render such alternative definitions as immaterial. After some strictures of WHO’s definition of
health by Saracci (1997, p. 1410) , he proposed a definition of health as “a condition of
wellbeing, free of disease or infirmity, and a basic and universal human right.” Impliedly, this
definition also defined those who are living positively with chronic disease as unhealthy. It
presents a health as a basic right, which is also problematic. In most parts of the world, health is
a commodity with an insurance premium, a price-tag, or it requires a pool from the public tax.
This also seems like a theoretical proposition that is not operational. It does not really account
for the multidimensionality of health. Therefore, it may not be considered a holistic and viable
alternative to the WHO definition.

Bircher (2005, p. 1) , on the other hand, defines health as “a dynamic state of well-being
characterised by a physical and mental potential, which satisfies the demands of life
commensurate with age, culture, and personal responsibility.” While this is stylishly holistic, it is
contentious due to the use of other concepts (e.g., age and culture) without unified definitions.
For instance, culture is complex, dynamic, and relative. This may imply that the definition of
health will also be relative and probably depend on the circumstances or societies. Additionally,
does the definition refer to biological age or social construction of age? This is part of the
complicatedness as the concepts used are not specific.

In an attempt to proffer a more acceptable perspective in the face of the continuous debate,
Larson (1999) proposed that health should be conceived using multiple models: medical, the
WHO, wellness, and environmental models. A combination of these models will be more holistic
beyond the use of only the WHO model or other definitions. Table 2.1 presents the models of
defining health. One major problem with model-based definition is that there could be more

4
models than expected. The model-approach does not present a whole definition. Later, every
profession will likely present a model of health beyond common understanding, and this will
generate more issues. The major strength of this approach is that it emphases the multifactorial
context of the concept of health.

Table 1

Models for defining health. (Source: Larson 1999, p. 125)

Medical model The absence of disease or disability

World health organization State of complete physical, mental, and social well-being and not
(WHO) model merely the absence of disease or infirmity
Health promotion and progress toward higher functioning,
Wellness model
energy, comfort, and integration of mind, body, and spirit
Adaptation to physical and social surroundings—a balance free
Environmental model
from undue pain, discomfort, or disability

Following the argument that there could be more models, a social model will dwell on Parsonian
definition that defines health as “the state of optimum capacity of an individual for the effective
performance of the roles and tasks for which he has been socialized” (Parsons 1972) . This is
more a sociological approach to health—a conceptualisation of health as a social element. Health
in this sociological sense is more inclined towards human capacity to fulfil their obligations,
participate in social activities (including work), and fulfil role expectations in the society in the
face of structural limitations. This conception is connected with both physiological and mental
models of health in the sense that the source of a social incapacitation could be from a biological
or mental limitation. The social model does not debunk the biomedical model. The model is
complementary to the medical model and signifies a perspective that is central in medical
sociology.

In a recent development, Huber et al. (2011) defined health as the ability to adapt and self-
manage in the face of social, physical, and emotional challenges. This definition was initially
proposed in 2008 (see Jadad and O’Grady 2008) . The definition seems to be receiving some
considerations, especially because of the use of “adaptation.” While the WHO’s definition
stresses on a complete state, this definition proposes adaptive capacity. Lancet Editorial (2009,

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p. 781) commented, “Health is an elusive as well as a motivating idea. By replacing perfection
with adaptation, we get closer to a more compassionate, comforting, and creative programme for
medicine—one to which we can all contribute.” The major strength of this definition is that it
takes account of the shift in health challenges in the twenty-first century. Unlike the period
before World War II when acute diseases were more prevalent than chronic diseases, now the
latter constitutes a greater burden. Chronic diseases require behavioural adjustments in terms of
self-care or management (see Sects. 2.6.2 and 10.1007/978-3-319-03986-2_8#Sec3 ). This is
why the idea of adaptation seems to be more current than that of “a complete state.”

With a critical stance, the definition by Huber et al. is also problematic. First, adaptation does not
mean the absence of diseases or infirmity. Adaptation may signify a number of limitations such
food or activity restrictions or behavioural constraints. Second, it may also mean continuous
treatment or dependence on medication. In the case of a chronic disease, adaptation does not
nullify the self-awareness of (undesirable) state of health. The shortcomings of the definition also
create opportunities for more deliberations.

Recognising the diversity, relativity and complexity of health, Blaxter (1990, 2010) presents a
descriptive analysis of health. One of the major dimensions of health identified by Blaxter
(1990, 2010) is the lay concept of health. This implies how different individuals define health,
which explains the relativity of the concept. The lay concept of health is essentially subjective
because it is based on people’s own assessment and judgment of whether they are healthy or not.
Blaxter (1990, p. 40) observed that the most “usual way of measuring self-perceived illness, as
distinct from the presence or absence of disease, is by means of symptom lists.” To the lay
population, absence of symptoms means health. From this perspective, Blaxter (1990) identified
the three “states” of health: freedom from illness, ability to function, and fitness. In this regards,
health is also perceived as energy and vitality in terms of fitness for functions: physical, social
and normative activities .

Blaxter (2010) argued that health could be defined, constructed, experienced, acted out, and it is
also dynamic. Definitions of health are often for operational use like the previous definitions that
have been considered. Construction of health stems from the lay perspective or individual’s
appraisal of state of health, which can be good or bad. Such construction also includes what a

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particular society qualifies as “health.” For instance, labelling reactivity (people’s reaction to a
particular condition) might influence designation or conceptualisation of health or illness in a
particular society (see sect. 10.1007/978-3-319-03986-2_8#Sec5 for labeling theory).
Experiential knowledge of health is phenomenological—derived from feeling of wellness or
otherwise, which emanate from the presence or absence of personal discomfort and pain. In
terms of “enactment” of health, the central consideration includes what people do to maintain
their health. Health is also a dynamic attribute because it fluctuates across biographical,
historical and contextual milieus. The state of health varies across lifespan, and is influenced by
a number of factors including personal (e.g., lifestyle) and structural factors (e.g., access to
health care) (see Chapter four). The conceptualisation of disease will be the focus of next
section.

Disease as a Conceptual Tool

Health has been conceived in a biomedical model as the absence of disease while the holistic
definition from the WHO signifies that health is not a mere absence of disease. Whichever form
the definition takes, the question now is “what constitutes a disease?” One major issue is that
disease is often conceived from a biomedical point of view. It can also have behavioural
manifestations, especially with regard to human functionality. The definition of health is
complex, so also is the definition of a disease. If the lack of health can be defined as not a mere
absence of a disease or infirmity, this signifies that there are a number of germ- and non-germ-
related (medical) conditions that can signify the presence of a disease. This, however, also makes
the definition of a disease complex because of variations in its conceptions. Mainly, Boorse
(1975, 1977) was engrossed in a practical and philosophical discussion of what health and
disease may entail. He defined disease as a type of internal state which impairs health (i.e.,
reduces one or more functional ability below typical efficiency). One major criticism of this
definition is the use of “typical efficiency,” which implies the presence of a reference group in
the definition of disease (Kingma 2007; Stempsey 2000) as a kind of comparative analysis. This
view is often referred to as a bio-statistical theory (BST) of health and disease. Kingma ( 2007)
argued that human species are different in functional capacity: what is normal in one group can
be abnormal in another and vice versa. Therefore, Boorse’s definition of health or disease is only
valid depending on the reference group.

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 Despite this criticism, Boorse’s arguments have been a significant reference point in the
discussion of health and diseases. Boorse discussed seven major themes that are prominent in the
discussion of what health or a disease entails. It is important here to examine the seven themes in
line with the notion of disease and see how important or otherwise those themes could be in
identifying a disease.

1. Pain, suffering and discomfort: generally what is called disease accounts for human suffering
by inflicting pain and discomfort, sometimes unbearable, thereby necessitating palliative care ,
like terminal sedation . Whitlow is a typical condition that could impose considerable pain on the
sufferer, although it requires a simple medical procedure to resolve. A reason why the argument
about pain may not be sufficient is because there are a number of normal procedures that require
medical attention as a result of pain and discomfort, but are not diseases, such as teething,
menstruation, childbirth, and abortion.
2. Treatment by physicians: normally diseases require the attention of medical doctors. A disease
should be treatable. However, Boorse submitted that there are some conditions that cannot be
treated, and doctors also attend to a number of conditions that are not diseases. With
medicalisation of life, there are medical expansions beyond treatment of disease, such as
certification of fitness for a study or travel. More so, circumcision, body modification or
enhancement, and family planning procedures cannot be regarded as diseases but require
attention of a physician.
3. Statistical normality: the species’ average level of performance becomes a yardstick for
determining normality and abnormality. There is also a measure of statistical normality of
clinical variables such as blood pressure, basal metabolism, weight, sugar level, height, pulse,
and respiration. Any measure beyond the normal range is usually termed as an abnormality or a
disease condition and signifies the need for medical attention. When normal blood pressure ends,
there begins hypotension or hypertension. This average of normality is derived from the rate of
mortality or functionality within normal and abnormal ranges. It is assumed that mortality or
dysfunctionality is often higher when below or above normal ranges. This may not always be the
case as clinical variables are measures of probability or propensity to a disease.
4. Disability: disease could also lead to many forms of disability. Poliomyelitis is a typical example
of a disease that can cause physical deformity. In another case, a disease may reduce active
participation of an individual in the social network, such as the inability to walk or stand.

8
 Pregnancy, for instance, could not count as a disease even though it comes with some limitations.
A number of skin diseases may not count as disease since they may not present with disabling
effects.
5. Adaptation: the ability to adapt to the environment has also been categorised as a form of
healthiness while those who are not fit are presumably diseased. Lack of adaptation prevents an
individual from meeting the average level of a species’ functionality. The presence of eumelanin
pigmentation in the skins of black Africans helps in adapting to their environment, but it does not
mean those with pheomelanin pigmentation cannot survive in Africa or that Africans cannot
survive elsewhere. Environmental can even inflict suffering on humans in the process of
adaptations.
6. Homeostasis: health is a state of bodily equilibrium while disease is a state of homeostatic
failure. But the process of human growth as Boorse observed is itself leading to homeostatic
disequilibrium.
7. Value: disease is undesirable while health is desirable. Health is thus a social value in human
society. However, it is also impossible to exclusively delineate disease from the point of
undesirability. Conditions such as shortness and ugliness cannot be counted as diseases even
though they may not be desirable.

Furthermore, a disease can also be defined as a state in which human capacity fluctuates and
represents a deviation from biomedical standard or normal human condition. Disease often
requires medical intervention. As noted earlier, not all that conditions which require medical
intervention constitute disease. A disease is a pathological state which can be diagnosed through
a competent medical analysis. Disease, however, does not always mean there must be a
pathological agent such as a virus or bacterium. Conditions such as infertility, gunshot wound,
fracture, drowning, and other forms of injuries/accidents also qualify as disease because they
represent an infraction on normal human condition.

More so, Fabrega (1973) explained that diseases usually present with a biological discontinuity.
Biological discontinuity signifies the presence of pathology in any part of the body or bodily
inactivity due to an injury. Some diseases have pathological agents (e.g., onchocerciasis [worm
infection], trypanosomiasis [spread by the bite of the tsetse fly], dracunculiasis [guinea worm],
trachoma [bacterial infection], malaria [parasites spread through a mosquito bite]), some are

9
mere deformities or birth defects (e.g., brain injury, autism, spinal bifida), while some are the
actual breakdown of organs (e.g., renal failure, blindness) or organ functional problems (e.g.,
impotency, ectopic pregnancy) . All these diseases have to do with biological problems and
constitute apparent forms of diseases.

Furthermore, Temple et al. (2001, p. 807) proposed a definition of disease with three basic
elements—“disease is a state that places individuals at increased risk of adverse consequences.”
The first element, “a state,” implies a physiological or psycho-social condition which explains
susceptibility to risk. Second, risk includes the possibility of impairment. Certain conditions put
individuals at a risk of diseases in the future. Therefore, both preventive and therapeutic
measures could be provided to avert or ameliorate adverse consequences or undesirable
situations. Meanwhile, adverse consequences include morbidity, disability, or mortality. The
definition adequately extends to genetic conditions in humans.

Despite these enormous arguments on the biomedical model of disease, it is important to note, as
Temple et al. (2001) observed, that disease is “a fluid concept influenced by societal and cultural
attitudes that change with time and in response to new scientific and medical discoveries.” One
major example that is often cited is the classification of obesity . In the pre-industrial era, obesity
was a sign of affluence and good living, while in the modern era it is a disease with enormous
research and development of medical interventions (including surgical procedures) to “cure”
obesity. Apart from the medical risks of obesity, the social and modern reconstruction of beauty
as a slim body figure also affects attitudes towards obesity. In addition, homosexuality was
previously considered a disease but is now normalised in many societies (Nordenfeldt 1993) .

The Realities of Illness

Illness and disease have been major traditional concepts in sociology and medical sciences. The
important role of these concepts for human-related medical endeavours was re-emphasised by
Nordenfeldt (1993) . These concepts are interwoven and often require some analytical
clarifications. Most often, people use the words interchangeable. As conceptual and practical
tools, they are not the same. The essence of this section is to make some conceptual clarifications
of these concepts and not to join the body of unending debate evident in the works of various

10
 scholars (including Boorse 1975, 1977; Hesslow 1993; Nordenfeldt 1993; Stempsey 2000;
Tengland 2007) . More importantly, sociologists have laid more claims on the notion of illness
because it is more of a behavioural concept than a medical one. Undoubtedly, illness has a
number of undeniable social, moral, and legal contexts.

In a simple illustration, disease is a form of pathology or medical problem, defect, or

impairment, while illness is a manifestation of such an impairment, defect/pathology, or
disability. Illness is a presentation of a medical condition in a way that limits the functional
capability of an individual in the society. This is why Nordenfeldt (1993) observed that to be ill
is to be in pain, to be anxious, or to be disabled. The notion of illness fits appropriately into the
concept of sick role described by Parsons (1951). It is a situation when an individual consciously
feels that he/she is unhealthy, sometimes as a result of discomfort and pain. Therefore, illness is
the live-experience of a diseased condition. While a diseased patient might not be real (i.e.,
without a self-awareness of the condition), an ill patient is real.

It can simply be observed that disease makes people ill. An individual is thus ill to some degree
if there is some vital goal of his/her which cannot be completely realised (Nordenfeldt 1993) .
Illness is a progression from the mere presence of a medical problem or condition to the
presentation of disabling symptoms and signs. The underlying meaning is that it is possible to
have a disease without being ill and vice versa—invariably it is possible to have a disease
without any awareness of it. Boorse (1975) advanced some clarifications on the character of
illness.

1. An illness is a reasonably serious disease with incapacitating effects that make it undesirable. It
is a condition that is obviously undesirable because of its negative attributes.
2. Illness requires treatment. It is a condition, which can be described as a medical problem in terms
of impairment, defect, or disability and thus requires medical attention.
3. Illness is often a valid excuse for normally criticisable behaviour. This implies that an ill person
may not fulfill normative roles and expectations. Instead of criticising an individual, people will
affirm that he/she is incompetent due to illness. This implies there is a diminished moral
accountability for the ill.

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4. Determination of illness is bound by appropriate normative judgments or a sociocultural context.
This implies that illness is a relative term as it could vary by culture, place, individual, and time.
The cultural notion of illness determines the kind of response and how serious some medical
conditions could be termed as mild, serious, or negligible.

From the foregoing discussion, it is evident that illness is culture-bound. It is socioculturally

defined. This is why Fabrega (1973) and Garro (2000) observed that illness is a universal human
experience with a cultural meaning. They observed that culture is a tool, which both enables and
restrains interpretive possibilities regarding an illness. This cultural interpretation of illness is
inevitable and important in a number of ways.

1. The first major interpretation is the normative definition of illness, when an individual could be
declared ill. In fact, the significant other may play a major role in identifying illness and referring
the individual to an appropriate care sector. There are cultural frameworks for recognising a
disease/illness through its signs and symptoms.
2. The second is aetiological categorisation—an attempt to determine why an individual is ill.
Cultural and historical experiences affect this causal classification of illness (see Sect. 2.7). If it
is an illness that is common in the community, a remedy may be available without much process
of diagnosis.
3. The third is the evaluation of therapeutic options. This is often influenced by aetiological
classification. Different societies have a number of causal explanations. Although natural
causation is predominant in western societies, there are other etiological classifications. The
same situation applies to the non-western societies. Fabrega (1973) , for instance, opined that the
social definition of illness forms the basis of a decision about medical treatment.
4. The last aspect is reintegration into the social system following perceived wellness. This is also
very important as the society plays a large role in absorbing a previously ill individual back into
the social system. This is often problematic in the case of mental illness as stigmatisation may
arise which may eventually affect the illness prognosis.

Disease/Illness Categories

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 There are various ways in which illnesses can be categorised. For the purpose of this sociological
explanation, categorisation based on acute, chronic, accident , and mental illness is adopted. This
categorisation also has sociological significance in terms of the dimensions of the diseases. It is
also important for medical sociologists to be aware of the nature of diseases and some basic
biomedical aetiologies and modes of transmission.

Acute Disease/Illness

An acute illness could be mild, moderate, or severe. Acute illness is by definition a self-limiting
disease, which is mostly characterised by a rapid onset of symptoms. These symptoms may be
very intense and resolved in a short period of time and, in some cases, could be life-threatening.
Most contagious diseases are acute in nature. The term “acute disease” is often an indication of
duration of the illness compared to chronic or sub-acute illness. Some examples of acute diseases
include influenza or the flu, bronchitis, tonsillitis, sore throat, appendicitis, ear aches, organ
failure, and breathing difficulties. Some acute diseases come with the prefix “acute” including
severe acute respiratory syndrome (SARS) , acute disseminated encephalomyelitis, and acute
bronchitis. Specifically, attributes of acute diseases include:

1. Self-limiting: acute diseases have short durations or a limited short course. It is easy to predict
that the disease will only last a few days. This also means that the disease could be resolved by
itself sometimes without medical intervention.
2. Sudden or rapid onset: more often than not, acute diseases inflict humans unaware. An
individual may wake up in the morning and discover he/she has the flu. The disease is often
rapidly progressive.
3. Communicable: most acute diseases can easily be contracted even by mere contact with a
sufferer. Sometimes they lead to outbreak (e.g., a cholera outbreak) and kill many people within
days of its spread.
4. Urgent care: acute diseases often require urgent medical attention. If prompt care is not taken,
the individual may die in a matter of a few days or weeks.
5. Rapid resolution: most often, response to treatment is very quick. If an individual is
hospitalised, it could be for a few days. It means that it can also be rapidly resolved .

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 Chronic Disease/Illness

The burden of chronic diseases is increasing in the world. Such illness has also been part of the
focus of many sociological studies because of peculiar attributes and their increasing burden all
over the world. The WHO set a goal to reduce the burden of chronic disease by 2 % every year,
thereby saving up to 35 million lives by 2015 (WHO 2005). The goal was set following a
realisation that chronic diseases are the major cause of death in almost all countries, accounting
for up to 60 % of all causes of deaths: 4.9 million people die as a result of tobacco use ;
2.6 million people die as a result of being overweight or obese; 4.4 million people die as a result
of raised total cholesterol levels; 7.1 million people die as a result of raised blood pressure
(WHO 2005). A chronic disease/illness often presents as a medical condition, which makes an
individual perceptually and perpetually ill. Major chronic diseases include heart disease and
stroke (cardiovascular diseases), cancer , asthma, chronic obstructive pulmonary disease (chronic
respiratory diseases), diabetes , obesity , ulcers, sickle cell diseases, and hypertension . Chronic
diseases have a significant impact on the population health and by 2015 will be a leading cause
of death in Nigeria and many other poor countries (WHO 2005).

The characteristics of chronic diseases include:

1. Slow onset: this is the major attribute of chronic diseases. It may take several years to develop or
to manifest any form of symptom. Smoking takes a long time to affect the smokers. Cancer may
take several years to manifest even when one has the risk. Chronic diseases have a slow
progression.
2. Protracted course: Even when a chronic disease is symptomatic, the sufferer may live with it
for several years, especially with proper medical management. For this reason, chronic diseases
impoverish millions of (already poor) households because such diseases often gulp a lot of
expenditures: its management is usually protracted and expensive.
3. Usually non-communicable: chronic diseases are sometimes called non-communicable diseases
(NCDs) . One cannot contract a majority of the chronic diseases by mere contact with a sufferer.
However, based on the other four attributes of chronic illness/diseases, HIV/AIDS is a chronic
disease that can be transmitted from one person to the other (see Sect. 10.1007/978-3-319-
03986-2_12#Sec5).

14
4. Chronic diseases are not self-limiting: the medical condition often gets worse with age or time.
This implies that they have a long span and are often irreversible. Even when the disease
pathogens are removed, the condition may reappear .
5. Treatable but not curable: chronic diseases are preventable, and they can also be managed, but
a majority are not curable. This is why the diseases constitute a major health burden in the world
today.

Injuries or Accidents

Injuries or accidents also constitute another form of health problem. An injury is usually sudden
and may lead to a serious or permanent disability or death. Most of these medical conditions are
always in the emergency unit or on a priority list in any triage system. Road accidents are the
major sources of accidents especially, in the developing world. Workplace injuries also account
for a substantial number of deaths each year. Most accidents are usually unintentional and
random. Injuries or accidents include drowning, fire-related burns, fall-related injuries,
poisoning, interpersonal violence , self-inflicted injuries, and war injuries. Approximately, more
than 5 million people die and over 100 million suffer from non-fatal injuries (sometimes
permanent disabilities) annually (Peden et al. 2002; WHO 2010) . While the global percentage of
deaths from road traffic injuries is about 25 %, the percentage in Africa is about 45 %
(WHO 2010). Figure 2.2 shows the global distribution of injuries by cause. Management of
injuries require rapid and responsive health care and other relevant agencies.

15
Fig. 2
The global burden of injuries by causes. (Source: Peden et al. (2002, p. 9) )

Mental Disease/Illness

Mental health simply refers to the level of psychological well-being of an individual. This often
has to do with the brain vis-à-vis thought, feelings, sensation, and intuition. About 14 % of the
global burden of disease has been attributed to neuropsychiatric disorders (Prince et al. 2007) .
Mental problems frequently manifest with behavioural changes that represent an infraction on
the social norms of the society. A mental disorder is socially disastrous to the individual and
could lead to total incapacitation or exemption from normal roles in the society. There are two
major divisions of mental illness, which include neurosis (minor) and psychosis (major). While
the former does not usually involve organic (brain) breakdown, the latter usually does. Examples
of neurosis include: obsessive-compulsive disorder, anxiety disorders, post-traumatic stress
disorder, phobia, dissociative disorder, minor depression, hypochondria, hysteria, and puerperal
neurosis. Psychosis involves loss of contact with reality. It is generally the worst form of mental
disorder. Examples of psychosis include bipolar disorder, schizophrenia, depression, substance-
induced mental disorder, dementia (Alzheimer), delusional disorder, and epilepsy. A mental

16
 disorder may not necessarily lead to death, but it is disabling—it could be acute or chronic.
Sartorius (2007) observed that stigma attached to mental illness is the main obstacle to the
provision of care for people living with mental disorders. The stigma is a mark or label on those
who are ill and their generations (see Sect. 10.1007/978-3-319-03986-2_8#Sec6 for the theory of
stigma).

Cultural Beliefs of Illness Causation

In all cultures, there are cultural classifications of disease aetiology or lay understanding of
illness. This is usually based on the traditions and belief systems. This implies that cultural
beliefs affect the perception of aetiology of diseases (Sylvia 2000) . Most of these beliefs are not
coherent with the biomedical beliefs and are sometimes unscientific. Irrespective of value
judgment about such beliefs, the realities of such beliefs cannot be debunked, so also the realities
of such causal connections. It is often the case for scientists to consider some local beliefs about
causality implausible, inexplicit, and inconsiderable in scientific explanations. However, local
beliefs are relevant in understanding the population health and in drawing behavioural
interventions. Sometimes, such beliefs are misconceptions, which need to be addressed.
Specifically, disease causation is often divided into four types: natural, supernatural, mystical,
and hereditary/genetic.

Natural Causes

A natural cause refers to the biomedical explanation of a disease. This conforms to the germ
theory of disease. The explanation is based on pathogenic causation such as microbial agents
including viruses, bacteria, worms, and fungi. This also includes injuries and accidents such as
broken bones and the ingestion of bad substances into the body. O’Neil (2006) observed that
other forms of natural causation include :

1. Organic breakdown or deterioration (e.g., tooth decay, heart failure, senility)

2. Obstruction (e.g., kidney stones, arterial blockage due to plaque build-up)
3. Imbalance (e.g., too much or too little of specific hormones and salts in the blood)
4. Malnutrition (e.g., too much or too little food, insufficient proteins, vitamins, or minerals)

17
This explanation is sometimes called mechanistic or naturalistic explanation of disease causation.
The diseases categorised with natural causes can be clinically or medically diagnosed.
Traditional African societies hold a coherent view on the biomedical explanation of illness as it
relates to natural causes, although some diseases may be explained based on multiple causalities .
For instance, small pox may be explained from a natural cause, and it can also be attributed to
anger of the god of small-pox (called Sanpanna) among the Yoruba of western Nigeria . This
means that, despite the natural cause attached to a disease, there could be other explanations, and
sometimes multiple therapies have to be employed.

Supernatural Causes

There is also a supernatural causation of illness. As Conco (1967) and Omonzejele (2008)
explained, this is the spiritual construction invoked to explain the “uncommon or out-of-the-
ordinary” types of sickness. It is further observed that it is made use of at a point where ordinary
empirical methods of treatment and explanation have failed. This typically deals with divine
attribution of illness. With the emergence of modern religions, such as Christianity and Islam ,
there is attribution of diseases to God. Such diseases may come as punishment for misdoings or
sins. References to divine infliction of diseases/plagues can be cited from both the Bible and
Quran in historical times. Especially among most religious adherents, there is a fatalistic belief
that disease or health comes from God. Such infliction will usually present with medically
unexplained symptoms or with medically explained symptoms that are beyond medical remedies.
This is a part of the belief system and such diseases require pleasing the God through repentance,
fasting, and prayers.

Disease could also come from the gods, spirits, deities , and other supernatural entities such as
wizards and witches. This traditional perspective of illness describes a different source of evil
(illness) caused by invisible spirits that exist within and outside human social boundaries
(Foster 1976) . These spirits inhabit trees, rivers, lakes, mountains, and deserted places around
the habitation (Bhasin 2007, p. 6) . In most African societies, there are gods or deities of the land
who need to be appeased from time to time, both at the individual and community levels. Lack of
appeasement from either of the levels could be detrimental. The people of the Kalahari Desert
also attribute diseases and health to Hishe (god). So also the Bantu of South Africa (like many

18
other groups in Africa) believes that supernatural entities can inflict pain or disease on
individuals. Conco (1967, p. 288) specifically explained that

[i]n varying degrees most rural Africans believe that it [supernatural causation] explains all
complexes of extra-ordinary diseases. They also believe that it is true, and this implies that they
are psychologically convinced, though they cannot give conclusive empirical grounds for its
truth. It is a metaphysical article of faith, and as such it cannot be verified or falsified
empirically, though it always has some claim to being factual.

The belief in supernatural causality is widespread in both rural and urban communities and
across groups whether educated or not. Foster (1976) and Garro (2000) noted that, among several
people, there is a wide belief in the supernatural cause of illness: the Mono of Liberia and Abron
of Cote d’ivoire believe that death is usually caused by external forces. Jegede (2002, 2005)
observed that among the Yoruba of western Nigeria , illness can be traced to enemies ( ota),
witchcraft (aje), sorcery or wizard (oso), gods (orisa), and ancestors (ebora). The belief of the
supernatural causes of illness is still highly prevalent and central in the explanation of illness in
Africa (Omonzejele 2008) .

In cases of supernatural causes, diseases are diagnosed through spiritual means, especially
through consultation with religious clerics or traditional healers. It is believed that these
categories of people have spiritual power to detect and prescribe a course of action in the
treatment of illness. Such therapeutic procedures are not amenable to science or are simply
beyond empirical comprehension and explanations.

Mystical Causes

The mystical causes are a part of what Foster (1976) described as a personalistic cause of illness .
Mystical retribution is defined as acts in violation of some taboo or moral injunctions, which
could lead to illness (Murdock 1978) . In traditional African societies, illness can result from the
violation of vital norms and values of the society. These norms are often concerned with the
traditions and spirituality of the community. Specifically, many African societies believe that

19
some individuals have “evil eyes” or possess a mystical power that can be used to inflict pain or
illness on other people in the society.

Illness as a result of mystical causes also present with symptoms that cannot be explained
medically or where explanation is possible, biomedical treatment is futile. Such patients are often
referred to the traditional or faith-based healers for appropriate deliverance or salvation from
such illness.

Hereditary and Genetic Causes

Hereditary diseases can be passed from one generation of same family to another. While heredity
is linked with genetics, not all genetic disorders are heritable. Most hereditary or genetic diseases
have natural causes, and some of them can be explained from supernatural causes. Many African
societies (e.g., the Yoruba of West Africa) believe that madness can be inflicted on a family and
it can continue from one generation to the other. The Yoruba call hereditary disease aisan idile,
literarily translated as “a family disease.” Treatment depends on the perception of the aetiology,
whether natural or supernatural. Some biomedical hereditary/genetic diseases include autism,
cancer, dwarfism, sickle cell anemia, cystic fibrosis, albinism, color blindness, myotonic
dystrophy, porphyria, and some forms of mental illness (e.g., Huntington’s disease). Hereditary
diseases have effects on the relationship patterns in the society as many individuals may not
marry from a family where a hereditary disease is perceived to exist.

One critical way of perceiving hereditary or genetic disease is through fatalism, especially
among Islamic communities of Africa. This is the attribution of such a condition to the will of
God claiming it has been destined that a person would have such a medical condition. The
Yorubas call this kadara or ayanmon (i.e., destiny). Especially in heritable genetic disorders in
children and adults, this fatalistic idea prevails. The idea can also be applied in cases of injuries
and accidents. This idea serves as a coping mechanism and aids reintegration into the society.
Since it is the will of God, discrimination is termed against the will of God. It helps the
individual to live and surrender to destiny, fate, or an act of God. Unfortunately, the idea does

20
not help in preventive measure. Fatalistic individuals tend to accept everything that comes their
way—if it has been destined, it is beyond human preventive measure.

In conclusion, this chapter has dealt with a lot of issues regarding health, disease, and illness. It
starts with the polemics on the definition of health by de-constructing some of the available
definitions. In the case of health, the goal is to work towards a state of perfection. No matter how
health is defined, nobody can be in a perfect state—whether “adaptation” or “a state of
completeness” is used. This argument does not, however, mean that available definitions should
not be reviewed.

The Main 3 Levels of

Healthcare System in Nigeria

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There are three main levels of healthcare system in Nigeria, unlike in some advanced countries,
that have four tiers of healthcare system, including quaternary healthcare. The structure or levels
of healthcare system in Nigeria follow the structure of the government. The federal government
handles the tertiary healthcare, the state handles the secondary healthcare, while the local
government takes charge of the primary healthcare. The National Health Bill (2014) determines
the standards and also regulates health service delivery in Nigeria, both private and public health
providers. The major stakeholders in the healthcare delivery in Nigeria are the federal
government, Health Maintenance Organizations (HMOs), Donors, NGOs, National Health
Insurance Scheme, State Ministries of Health (SMOHs) National Primary Health Care Dev.
Agency (NPHCDA), Local government areas, Ward Health Authorities.

In Nigeria, most patients fund their medicare out of their pocket, unlike in advanced countries,
where there are insurance schemes and taxes. The National Health Insurance Scheme (NHIS)
does not cover the health insurance of most of the population.

22
Healthcare system in Nigeria suffers from a lack of proper health funding and investment, with
the government committing only about 5% of the budget to health. WHO ranked Nigeria as low
as 156th out of 191 countries, based on the quality of medical system and healthcare delivery.

The three levels of healthcare system in Nigeria are:

 Primary Health Care

 Secondary Health Care
 Tertiary Health Care levels of healthcare system in Nigeria
Primary Health Care

Primary Health Care (PHC) operates at the community level and is the first point of contact for
patient. In Nigeria, most of the healthcare providers in the primary healthcare centres are nurses
and community health workers rather than qualified doctors. Most patients bypass the primary
healthcare in Nigeria and self-refer themselves to higher levels of healthcare, creating an
overload of patients at the referral facilities (secondary and tertiary facilities). This creates
problems as minor illnesses which the PHC can handle moves to facilities suited for severe
conditions. The National Primary Health Care Development Agency (NPHCDA) is supposed to
streamline the referral system of patients from the PHC to the secondary or tertiary healthcare,
though they are not effective in this function. In Nigeria, the Primary Healthcare are the health
centres in the LGA, communities, wards, villages. They have more public health centres.
Examples of primary care are health centers, clinics, dispensary.

Secondary Health Care

This is an intermediate healthcare level of healthcare. The states government through their
ministries of health, handle the secondary healthcare system while also providing technical
support for the primary healthcare.The different secondary health care facilities are general
hospitals, comprehensive health center, district hospital, specialist and general hospitals. At the

23
secondary level, there are good number of both public and private sector involvement in the
provision of healthcare.

Tertiary Health Care

At the federal healthcare level, the Federal Ministry of Health (FMOH) handles the policy
making, technical support, national health management, health services delivery. The federal
government handles the tertiary health care in Nigeria through institutions such as teaching
hospitals, federal medical centres (FMCs), national laboratories.The federal government also
helps to coordinate the activities of the other lower health care tiers such as the secondary and
primary healthcare. The tertiary healthcare has a high percentage of public facilities just as the
primary healthcare.

History of health social work

Going by history, Carton (1984) said social work in health care setting started in Great Britain,
Europe, the United States and Canada dated back to the end of the nineteenth century and it is
one of the oldest established fields of professional social work practice. It was also documented
that Medicare finding in the early 1960s, provided universal, accessible, portable and
comprehensive health care to all Canadians which resulted in the rapid growth of the health care
system. Social work departments in hospitals developed as integral health care services; home
care services also expanded with social work services as key components in many parts of
Canada. Canadian association of social workers (2006) later reviewed that, the term “health
social work” refer to the professional contributions in both health and illness. This practice is
said to be in relation to institutional and community client social functioning, precipitated or
exacerbated by actual or potential physical or mental illness, disability or injury. Health social
work has the ability to move the primary health model forward with a greater emphasis on health
promotion, prevention of illness and injury and the management of chronic disease. Empirical
reports (evidences) also indicate that social support and social networks play a major role in the
health of individuals, families, groups and communities. Social workers bring strong tradition
based in the ecological approach as well as one that integrates the provision of service within the
multiplicity of settings.
Social work in health care setting

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The duties of health social workers vary with the health care setting. They may work in a
hospital, hospice, assisted living center, nursing home, physical rehabilitation center, clinic,
home health care agency, or drug rehabilitation or mental health centers. Elizabeth (2005)
records that, health social workers often work with other agencies and have to travel short
distances for meetings with the agency members. Health social workers may also work in health
care facility or make home visits to work with their clients. In the same vein, Gilbert (2003)
earlier posits that social workers confer with other agency workers or team members to assess
client’s needs and make plans for the client’s care. The hours of work vary for the social worker
and it depends on the facility or agency within which he is employed. The work hours are usually
between 8am-5pm Mondays to Fridays. However, health social workers may be required to work
for extra hours as needed for emergencies. The social workers may as well be required to work
during evening hours and on weekends to better serve the clients both at the urban or rural areas.
The health care setting staff includes the personnel who provide the necessary services for
example, physicians, social workers, nurses, and hospital attendants among others. Health care
setting therefore, is a practice area in which assessment, care and treatment address the physical,
mental, emotional and social well-being of the clients. Prevention, detection, and treatment of
physical and mental disorders with the goal of enhancing the person’s bio-psychosocial and
spiritual well-being are also addressed in the health care setting. Premised on this, Barker (2003)
affirmed that, appropriate service delivery facilities such as hospitals, hospice, assisted living,
medical centers and outpatient clinics including educational and environmental facilities work
together to help prevent the spread of diseases. Susan (2001) also opined that, many public and
private social welfare agencies such as public welfare departments, adoption agencies, family
service agencies, neighborhood centers, probation and parole department are perceived as
primary setting for social workers. Hospitals, medical clinics and schools are secondary setting
because their primary service is not social work. According to Charles (2008), the main setting
for medical social work is the hospital. He also recorded that, Doctor Richard Cabot first
introduced social services department into the Massachusetts general hospital in Boston in 1905.
It should be noted therefore, that medical social work teach medical school courses in which they
convey their professional knowledge of the socio-psychological component of illnesses and of
the treatment processes. Charles (2008) further affirms that it is becoming increasingly
recognized that psychological processes are causative factors in nearly every illness in stress

25
related illness, alcoholism, depression, drug addiction, heart conditions, hypertension and
susceptibility to viruses, bacteria, and other infections. The patient emotions and motivation for
recovery also substantially affect the treatment process. Sexually transmitted diseases (including
AIDS) and cirrhosis of the liver for instance, may evoke feeling of shame and guilt because of
the stigma attached to these illnesses.
In the same vein, Williams and Joseph (2004) posits that, a miscarriage may result in a wide
variety of emotional reaction that needs to be dealt with. Adjusting to a chronic or permanent
disability also evolves a variety of negative psychological reactions. Therefore, medical
treatment teams depend on social workers to attend to social and psychological factors that either
contributing causes of medical ailment or side effects of a medical condition. Through interviews
with the patient and members of his or her family, the social workers gain a perspective on the
social and emotional component of the illness and how these components may affect treatment.
Linda, David and Caroline (2005) asserts that, the job of medical social workers in the health
field is a dynamic one that requires continued study. Social workers in hospitals therefore tends
to be short term and crisis oriented because there is generally a fairly rapid turnover of patients.
Social workers are often involved in discharge planning - making arrangement for patient to
return to their families or to a convalescent home. Most times too, health social workers must act
as advocates to ensure that the rights of patients are secured and that their needs are best served.
Although social workers in medical setting are involved primarily in direct service to patients
and their families, there are occasions when they engage in activity planning and administration
of programs such as therapeutic sessions.
Further, Tomaszewski (2004) also documents that, the development of specialized clinics and
programs for providing genetic counseling, abortion service, family planning, service to the
people with AIDS or to people who are HIV positive, service to rape victims, service to the
terminally ill, treatment for alcoholics, drug abusers and people with eating disorder has created
new opportunities for social workers in the health field. Also, social workers are getting involved
in advocating for programs that will assist in reducing discrimination against those who are HIV
positive and those who have AIDS. Health social workers have become case managers for many
people with AIDS to make sure that, pressing medical, financial, social, and other needs are met;
and that, the most cost-effective care possible is provided. Susan (2001) further asserted that,
health social workers also work with high risk groups including teenage mothers, women

26
requesting for abortions, drug and alcohol abusers, people undergoing organ transplants, severely
depressed or highly anxious people, and people under stress, people attempting suicide,
amputees and individuals with eating disorder.
It is also pertinent to note that, death is a frightening event. Perhaps, this is the reason why
Joseph (1980) affirmed that, the fear of death is felt universally in all cultures. Because most
people die in hospitals, there is the need for health social workers to assist the terminally ill
person to a peaceful death through counseling. Although, health professionals are committed to
recovery and to healing, they are also trained to be ready to assist the sick persons and their
families during and after this period. A health social worker therefore needs improvement on
skills and knowledge about how to counsel people with wide variety of medical conditions.
However, counseling the terminally ill person requires a high level of emotional maturity, a well-
thought-out identity and a high level of competence in counseling.

Roles of health social workers

The roles of the health social workers are enormous as earlier mentioned. Mojoyinola (2004)
lists the roles of the health social workers as follows: assessment team member; investigating
clients social background; supportive advice to help clients to cope with illness; using counseling
to help client’s to adjust to new situations; help both patients and families with problems that
accompany illness; interview patients or family members; referrals; assist patients to improve
their personal and social function; work with community to combat social problems; help other
professionals to understand social, emotional and environmental factors underlying his/her
illness. Other roles include: helping to plan activities that enhance hospital programmes and
resources; playing a critical role in discharge planning; counseling patients on rehabilitation and
employment programmes and arranging for follow up care.
Mojoyinola (2004) observes that, for a successful social work practice in hospitals, the health
social workers are expected to enjoy working with people, help people to overcome their
problems, empathize with people in difficulties, have a sympathetic and caring nature, have
strong team work skills and have good communication and organizational skills. With this
information, it could be deduced that the health social workers perform useful roles in hospitals.
These include: assessment; diagnostic; therapeutic; advocacy linkage, rehabilitative and follow-
up roles. Health social workers also perform the following specific responsibilities: assessment
of clients’ problem to establish a definitive diagnosis, interpretation of diagnosis and treatment,

27
interview and counseling of patient and his or her families, preparation of case records and
correspondence among other responsibilities.
In the same vein, Diana and Aaron (2008) affirms that, health social workers coordinate services
for and counsel patients and their families in a variety of ways in health care setting. Williams et
al (2004) also asserts that, social workers are also found in hospitals, schools, hospice and
anywhere support and guidance is needed. Victims of crime, trauma or abuse also may especially
benefit from the services of health social workers. Some other roles in health social work also
include: discharge planning, crisis intervention, mental health evaluation, physical dependency
evaluation, short term decision making, counseling, facilitating support groups for example,
Cancer support group, family rehabilitation group, ethnical decision-making counseling, grief
counseling, specialty evaluations and coordination such as on renal transplant team, child abuse
investigations and reporting. Charles (2008) concludes that the most significant role of the social
workers in health care is to help people who are dealing with a medical problem to function
within their situation. The social workers who specialize in health care work with clients and the
families to provide services necessary to make their lives easier for the duration of the clients’
illness, and to help them deal with the consequences, directly related to that illness.
In support of the above, Andrea Santiago (2003) earlier affirm that medical social workers
coordinate services for and counsel patients and their families in a variety of settings which
include hospitals, schools, hospice and anywhere support and guidance is needed. Andrea said
further that, victims of crimes, trauma, or abuse also may benefit from the services of health
social workers. In the same vein, Elizabeth (2006) posits that typical health social workers are
scheduled 24/7 and if not, there is an on-call arrangement so that a social worker can be reached
at all times in case of emergency or crisis. A typical day in hospital may begin with a review of
the new admissions to the facility, current referrals and unresolved cases and issues from the
previous day. The day will often continue with rounds on the various nursing units to collaborate
with the physicians and nurses in planning for the patient. It is imperative that social workers
will spend part of his or her day implementing plans for patient’s discharge or problem
resolution. This obviously includes patient, family and healthcare team meetings.
Another big role of the medical social workers is crisis intervention. This implies that the social
workers’ day never go as expected. There may be a death on one unit, where the family needs
grief counseling; a suspected child abuse case on another unit, where an evaluation needs to be

28
made to assist the team in reporting to child protective services. There are members of the health
care team and patients who always need to talk to the social worker instantaneously. Therefore,
social work in health care requires healthy dose of patience along with great skill in prioritizing
case intervention. The medical social worker’s day may end with finishing, charting and
wrapping up documentation, such as statistics, paper work or data entry and in an ideal situation,
debriefing with colleagues. Often, the social worker is the only one who sees things from a
systems perspective and can remove barriers that seem to be immobile.
The medical ethics training equips the social workers to provide ethics consultations in very
difficult situation. To be successful in health social work, the national association of social
workers (2005) highlights the following prerequisites: Knowledge of medical terminology;
Understanding of the roles of the health care team; Knowledge of the community facilities and
resources for discharge planning; Crisis intervention skills; Short term counseling skills;
Knowledge of the care planning and discharge planning processes. It is on this premise that
Barker (2003) recommends that the prospective medical social workers must make sure they
have dealt with their own issues and fears before trying to help others. Health social workers also
need to have a strong family, colleagues or friend circle support. It is noteworthy therefore that,
health social work is a stressful role. The health social workers are often expected to be the glue
that keeps the discharge plan together. This is a big expectation and a role only for the most
‘together’ and ‘mature’ practitioners who often binds the health care team together.

29