Since April 7, 1948, the Constitution of the World Health Organization (2010) has utilized an intuitive definition of health by suggesting that health is “a state of complete physical, mental, and social well-being.” While this definition might be intuitive and even accessible to a wide audience; the defininition is not necessarily researchable across health disciplines. Integrating principles of health might begin with a common-sense definition of health that can also be upheld across existing naturalistic and holistic perspectives. Without operationally defining functions that drive physical, mental, and social well-being, it is a challenge for multidisciplinary collaborators to unite under the WHO mission. Further, without a common definition of health, important communications from patients to doctors, from subjects to researchers, from researchers to collaborators, and from peer-reviewers to peer-reviewees, can become fragmented or lost in translation. In the proceeding sections, a common-sense definition of health is used to present the first principles of A Philosophy of Health.Principle 1: “Health” is the state of maintainable-ease of functioning. A “disease” is a state of prolonged-dysfunction that prevents ease
Chronic diseases emerge from prolonged exposure to dysfunctional behaviors like smoking, alcohol abuse, unhealthy diet, and inactivity (Mokdad et al., 2018) that also create dysfunctional expressions of life functions. Smoking creates dysfunctional breathing; alcohol abuse creates dysfunctional drinking; sugar binging creates dysfunctional eating; and sedentary behavior creates dysfunctional moving. When these health risk behaviors lead to chronic disease, they have already prolonged dysfunctional breathing, drinking, eating, and/or moving.
The chronic smoker breathes in smoke so frequently that he no longer experiences an ease-of-breathing. Rather, his breathing becomes short and shallow. Prior to the emergence of lung tumors, the chronic smoker prolongs dysfunctional patterns of breathing. The “couch potato” sits so frequently that he no longer experiences an ease-of-movement. Rather his movement becomes rigid and limited. Prior to the emergence of cardiovascular dysfunction or obesity, the sedentary person prolongs dysfunctional patterns of movement.
If chronic smoking facilitates prolonged-dysfunction in breathing, and sedentary behavior facilitates prolonged-dysfunction in movement, what do functional breathing and moving look like? Healthy breathing and moving (as well as eating and drinking) are characteristic of an ease of one’s functioning that can be maintained in normal conditions. For example, the chronic smoker and the “couch potato” might report momentary-ease in breathing and posture when engaging in their health risk behaviors; but they do not maintain that ease outside of smoking or sitting. Conversely, the yogi might report that their yoga practices expose them to momentary dis-ease in breathing and moving that lead to maintainable-ease in breathing and movement in everyday life. In contrast to disease as a prolonged-dysfunction, healthy functioning can be commonly sensed as a maintainable-ease of functioning.
When observing a disease, perhaps we are observing a prolonged-dysfunction that prevents ease. Rather than define health as the absence of disease (as seen in BST), notice here how we instead define disease in relation to health; and we define health in relation to maintainability, ease, and functioning. Consideration of “maintainable-ease of functioning” will allow us to consider how not all “dis-ease” is bad (i.e. exposure to acute dis-ease/stress maintains healthy functioning in the long-term); and not all “ease” is good (i.e. avoidance of stress and prolonged “comfort” creates fragility seen in sedentary behavior). We propose that:1.
Dysfunction parallels a state of “dis-ease”; and prolonged-dysfunction parallels the state of Disease.2.
Function parallels a state of “ease”; and maintainable-ease of functioning parallels the state of Health.
This definition of health will be applied in the proceeding principles to integrate naturalistic and holistic perspectives of population health.Principle 2: Health emerges from maintainable-ease of functioning at multiple levels. Maintainable-ease of functioning in the general population can be observed at the level of the cell, the self, and the society simultaneously
Cooperation across multiple levels of functioning is required for the organization and adaptation of living systems (Nowak and Sigmund, 2005; Antonucci and Webster, 2014). When developing an integrative model of health, it is important to consider how biological cells, individuals, and the larger society simultaneously play a role in population health (Xavier da Silveira dos Santos and Liberali, 2019; Antonucci and Webster, 2014). In this philosophy, we define health from three levels: cells, selves, and societies. What happens when these levels do not function in cooperation?
When the functioning of cells disrupts the functioning of the self, a state dis-ease in the self can follow. For example, prolonged dysfunction in autoimmune conditions can lead to prolonged dysfunction for the (individual’s sense of) self by triggering depression, decreased motivation, or anxiety (Lougee et al., 2000; Garud et al., 2009). The reverse can also be true. When the functioning of the self (i.e. one individual) disrupts the functioning of their cells, a state dis-ease in the cells can also follow. For example, prolonged sugar binging and addictive eating can lead to prolonged high blood sugar and pancreatic dysfunction seen in diabetes (De Koning et al., 2011; Imamura et al., 2015). Cells and selves are not separate.
When the functioning of the self disrupts the functioning of the society we observe a state dis-ease in the society. For example, one person’s unprotected sex with multiple partners can also lead to epidemics and social conflicts. The reverse can also be true. When the functioning of the society disrupts the functioning of the individual, a state dis-ease in the self can follow. For example, dysfunctional social conditions (as seen in Rutter, 1998), can lead to prolonged psychological and behavioral dysfunctions of individuals. Selves and societies are not separate.
When the functioning of society disrupts the functioning of cells, a state of dis-ease in the cells can also follow. For example, prolonged dysfunction in society in the form of misguided values about cleanliness, can lead to over-sanitization practices that create superbugs and antibiotic-resistant bacteria (Zaccheo et al., 2017; Finkelstein et al., 2014; Bower and Daeschel, 1999). The reverse can also be true. When the functioning of cells disrupts the functioning of the society, a state of dis-ease in the society can follow. Prolonged dysfunction in cells from naturally occurring parasites (e.g. Yersinia pestis [Cui et al., 2013]) can lead to prolonged dysfunctions like the economic collapse following 14th century Black Death (Haensch et al., 2010). Cells and societies are not separate.
What does health look like when these levels work together? Recent reports on the Blue Zones (i.e. the areas of the world where populations live significantly longer and healthier than the average) demonstrate that healthy functioning at these levels enhances physical longevity and mental wellbeing in populations (Buettner, 2012; Poulain et al., 2013). Buettner (2012) reports on how Blue-Zone populations intentionally and habitually enrich their physical bodies with healthy eating and physical activity. In addition to integrating physical and behavioral practices, these communities also integrate behavioral and social practices, such as, goal-setting, meditations/prayer, social engagement, pursuit of purpose, and community gathering. Humor is used by individuals and groups as a means to practice ease when challenges present themselves (Buettner, 2012). Blue Zone communities place value upon physical/natural, behavioral and social processes, generating them intentionally and habitually.
Both states of ease and dis-ease can teach us about the contributions of cells, selves, and societies to population health. Although it is important to be able to observe the levels separately to describe their contributions, it is also important to consider how the levels integrate to impact healthy publics. We acknowledge that meaningful changes can be observed above and below these levels (e.g. at the level of the biosphere and genome). However, this initial paper will introduce levels that are most proximal and accessible to the experience of a general readership (Fig. 1).Principle 3: Health emerges from systems whose primary purpose is to generate maintainable-ease of functioning at a respective level
We propose that systems exist at each level with the purpose of generating maintainable-ease of functioning at that level. The biological immune system, an individual’s system of health behaviors, and the social system will be observed as systems that generate maintainable-ease of functioning in cells, selves, and societies respectively (Fig. 2).Principle 3a: The biological immune system is directly responsible for maintainable-ease of functioning at the level of the cell
Throughout the course of human evolution, the complexity and biodiversity of the human body continued to increase (Rodríguez et al., 2012). What keeps the trillions of cells and microorganisms in cooperation in a human body? The biological immune system maintains functional cells (Rodríguez et al., 2012). Although it is documented that the functioning of the biological immune system has implications for behavioral functioning (Ader, 1974, 2000; Johnston et al., 1992; CDC, 2016) and social functioning (CDC, 2016; Reidel, 2005; Cutler and Miller, 2005) the system’s primary purpose is supporting functioning in the cellular/biological system.Principle 3b: Health behavior is directly responsible for maintainable-ease of functioning at the level of the self
Throughout the course of time, the complexity of human behavior, has continued to increase (Boulding and Khalil, 2002). What keeps an individual in a state of balance during times of rapid change? One’s system of health behaviors (e.g. one’s practices of breathing, drinking, eating, and moving) maintain a functional self. Although it is well documented that the behavior of the individual impacts biological functioning (Fadel, 2013, 2015) and social functioning (Omer et al., 2009), one’s system of health behaviors directly impacts one’s experience of (or one’s ‘sense of’) their “self”.Principle 3c: The social system is directly responsible for maintainable-ease of functioning at the level of the society
Throughout history, the social diversity of human societies continued to increase. During periods of rapid increases in social diversity and cultural integration, what supported cooperation in the society? Social systems (e.g. public governments, private social organizations, religious/spiritual organizations) emerge to maintain a functional society. Although it is well documented that a social system can impact biological functioning (CDC, 2016; Riedel, 2005; Cutler and Miller, 2005) and behavioral functioning (Buettner, 2012), the social system’s primary role is to maintain functions at the level of the society.Principle 3d: By considering health as maintainable-ease of functioning generated by systems, we have the ability generalize health across levels
To observe health at the level of the cell, the self, and the society simultaneously, we consider systems that support maintainable-ease of biological, behavioral, and social functioning. The biological immune system, an individual’s system of health behaviors, and the social system make meaningful contributions to the functioning of cells, selves, and societies, respectively. While these systems are not the only systems that impact each level (e.g. one’s cardiovascular system impacts cells, one’s “personality” impacts the self, the environment impacts society), the biological immune system, health behavior, and the social system have great implications for population health from their respective levels; and they can be operationalized at these levels based upon their functions.
By considering health as maintainable-ease of functioning (rather than maintained biological structures) at multiple levels, we set a point of reference from which to integrate important determinants of population health. When taking the structuralist’s perspective, the biological immune system, health behavior, and social systems appear as distinctly separated. When taking a functionalist’s perspective, the biological immune system (i.e. the integration of host defense functions and microbiota functions), one’s (system of) health behaviors (i.e. the integration of decision-making/executive functions and habits/habitual life functions), and the social system (i.e. the integration of population values and population behaviors) appear together in A Philosophy of Health.Principle 4: Each system employs two general functions—variation and precision—to generate maintainable-ease of functioning at a level
The functionalist perspective allows us to observe systems based upon their functions. The biological immune system will be observed as an integration of host defense functions and microbiota functions (Hooper and Littman Macpherson, 2012); (2) an individual’s system of health behaviors will be observed as an integration of decisions/executive functions and habits/habitual life functions (de Bruin et al., 2016; Verplankern, 2005; Norman et al., 1998; Prochaska et al., 1994; Prochaska et al., 1991); and the social system will be observed as an integration of actively functioning values and population-wide behaviors that function in relation to those values (Dowling and Pfeffer, 1975; Cotgrove and Duff, 1981).
By researching the role of these functions at each level, we distilled two general functions of each system: variation and precision. Variation appears in the functions of each system that generate a range of abilities, the “varied-abilities”, that sustain health in presently changing conditions. The microbiota, habits/habitual life functions and population behaviors will be observed (in Principle 4a) as the variation-functions of the biological immune system, health behavior, and the social system, respectively. Precision appears in those functions that prioritize and organize the patterns of variation that can sustain health at a level in future, changing conditions. The host-defense functions, decision-making/executive functions, and values systems will be observed (in Principle 4b) as the precision-functions in the biological immune system, health behavior, and the social system, respectively.
Consideration of a complementary relationship among precision and variation is not novel. Precision and variation have been discussed as central to the development of neural and biological systems (Hiesinger and Bassem, 2018). Discussions of precision and variation have also provided important insight into research on the biological immune system (Albert-Vega et al., 2018; Brodin et al., 2015). Through this philosophy, one can go beyond biological systems to observe how precision (in the form of host-defense functions, decision-making/executive functions, and values) and variation (in the form of microbiota functions, habits/habitual life functions, and population-wide behaviors) integrate to generate to maintainable-ease of functioning in cells, selves, and societies simultaneously (Fig. 3).Principle 4a: Variation is responsible for generating the range of abilities, the “varied-abilities”, that can express ease-of-functioning in presently changing conditions
Without functional variation, life is fragile because the present environment is always changing (Taleb and Blyth, 2011). Fragile systems’ inability to experience changing conditions (in part) relates to limited variability. Conversely, adaptive system’s ability to experience changing conditions (in part) relates to functional variability (Taleb, 2012). When one microorganism in the microbiome takes over, biological fragility reflects a state of infection. When one habit takes over, behavioral fragility reflects a state of an addiction/dependence. When one population behavior takes over (e.g. when economic participation or access to food is restricted to a small percentage of the population) social fragility reflects a state of social/civil unrest.
The human microbiota is comprised of trillions of microorganisms, such as bacteria, fungi, and viruses. When variability in the human microbiota exists, an ease of functioning, or “homeostasis” in cells can be expressed in the present biological/ecological environment (Parfrey and Knight, 2012; Bogaert et al., 2011; Claesson et al., 2011). Research demonstrates that variation in the microbiota impacts the health of human cells by metabolizing complex carbohydrates, converting proteins to neural signals, and modulating diurnal rhythms that maintain biological homeostasis (Clemente et al., 2012; Rothe and Blaut, 2012; Blaut and Clavel, 2007; De Vadder et al., 2014). When variation in the microbiota is dramatically limited or changed (e.g. following antibiotic overuse), cellular tissue in the human body is fragile and vulnerable to infections, allergies, and inflammatory outbreaks (Francino, 2016).
When one’s habitual life functions (e.g. breathing, drinking, eating, and moving) and one’s healthy habits (e.g. one’s weekly exercise schedule, or weekly meal preparation) can be expressed freely, an ease of functioning is felt by one-self in the present environment. When life functions are no longer expressed with ease (e.g. breathing and movement are compromised due to prolonged sedentary lifestyle), or when a single habit takes over one’s lifestyle (e.g. smokes breaks “must” occur every 30 min), an individual is vulnerable to stressful outbreaks and chronic states (Al’Absi, 2011; Conrad et al., 2007; Suess et al., 1980; León and Sheen, 2003; Parrott, 1999; Koob, 2008).
When the basic human rights in a society are preserved in the present (e.g. right to life, freedom of speech; right to property), human populations have the ability to freely engage in the population-wide behaviors (e.g. health behaviors, social behaviors, economic behaviors) that support a functioning society. Health behaviors drive health and longevity. Social behaviors drive communication and cooperation. Economic behaviors drive goods and resources. When these population-wide behaviors are chronically restricted in a population (e.g. poor access to health care, oppression of free-speech, economic crash), societies become vulnerable to social/civil unrest [as commented historically by Victor Frankl (1985), Alexander Solzhenitsyn (2003), Franklin D. Roosevelt (1941), and Dr. Martin Luther King (1985)].
Variation is essential so that a system has varied-abilities that can express ease-of-functioning in present environmental conditions. Dramatic and prolonged restrictions to variation in the microbiota, habits/habitual life functions, and population-wide behaviors characterize fragile and vulnerable states in cells, selves, and societies. Conversely, functional-variation supports resilience, robustness, and antifragility (Taleb, 2012). This does not mean that infinite variation is desirable; however, in this philosophy, precision is responsible for organizing expressions of variation so that the system does not degrade into unpredictably random variation or chaos (see Principle 4b).Principle 4b: Precision is responsible for prioritizing and organizing the patterns of variation that maintain ease-of-functioning in future, changing conditions
Some environmental changes are too challenging for ease to be expressed in the present. However, following an exposure to challenging conditions, some systems adapt and become more functional (Taleb, 2012). Without the ability to functionally organize after stressors, a system degrades into disorder or chaos over time. Host-defense functions, decision-making/executive functions and values systems prioritize and organize variation in the microbiota, habits/habitual life functions, and population behaviors respectively.
When a pathogen invades the biological system, precise responses must occur to organize this potentially chaotic situation. At the level of the cell, a functional host-defense system (comprised of the innate, adaptive and complement immune system branches) organizes the biological system so that functional invaders (i.e. symbionts) and healthy cells are maintained and dysfunctional invaders (i.e. pathogens) and damaged cells are removed (Hoeb et al., 2004; Janeway, 1992; Janeway and Medzhitov, 2002; Janeway et al., 2014). When precision is dysfunctional, the host-defense system may (1) fail to prioritize responses to a costly invasion, leading to a state of infection; or (2) the host-defense system might prioritize dysfunctional responses to the cells of body that prolong a state of autoimmunity (Naor and Tarcic, 1982).
When a bad habit emerges, precise responses must occur to organize this potentially chaotic situation. At the level of the self, functional decision-making (or at smaller scales executive functioning) prioritizes and organizes behavior so that functional expressions of habit (or at smaller scales, habitual life functions) are prioritized regularly, and dysfunctional ones are replaced or minimized (de Bruin et al., 2016; Prochaska et al., 1994; Prochaska and Prochaska, 2016; Prochaska et al., 1988; Redding et al., 2011; Weissenborn and Duka, 2003; Bickel et al., 2012). When dysfunctional, decisions may (1) fail to prioritize responses that remove a costly expression of habit (e.g. a teen started smoking cigarettes to “be cool” and now has to smoke in the bathroom before each class to get through the day; by not deciding to move at work, one’s breathing becomes shallow and movement becomes rigid); or decisions may (2) prioritize habits that prolong dysfunction despite knowing the dangerous consequences (e.g. an adult continues smoking cigarettes despite knowing the family’s history of lung cancer; an adolescent continues binge on sugar despite a diabetes diagnosis).
When dangerous population-wide behaviors threaten life in a society, precise responses must occur to organize this potentially chaotic situation. At the level of society, the agreed upon values organize the social system so that functional population behaviors are prioritized and dysfunctional population behaviors are minimized. Functional values prioritize behaviors that support the society (e.g. as seen when societies mandate that students get certain vaccines before attending University), while also setting standards that remove/replace behaviors that threaten the society (e.g. new laws create legal repercussions for risk behaviors in society). Without values that functionally prioritize population-wide behavior, society may (1) fail to prioritize responses to a dysfunctional population behavior (e.g. as seen during AIDS epidemic of the 1980s due to insufficient public health values around safe sex); or society may (2) prioritize dangerous behaviors that can prolong societal dysfunction (e.g. the antibiotic resistance crisis (Ventola, 2015; Michael et al., 2014) has been attributed in part to the over-valuing or over-use of antibiotic medications in healthcare practices).
Precision is essential so that a system can maintain ease-of-functioning in future, changing conditions. When precision does not adequately detect the presence of costly conditions, a response may not be prioritized (e.g. as seen during acute infection, addiction/dependence following a surgery, the AIDs outbreak in the 1980s). When precision prioritizes responses that prevent ease longitudinally, dysfunction is prolonged (e.g. autoimmunity, continued smoking despite family history of cancer, misguided values that create an antibiotic-resistant bacteria). Through dysfunctional-precision, the conditions for life in cells, selves, and societies becomes disordered over time. Through functional-precision, a system prioritizes responses that maintain ease-of-functioning in future conditions. Prioritizing functional microorganisms (i.e. symbionts) supports the developing life of cells; prioritizing functional habits (e.g. weekly exercise) and habitual life functions (e.g. diaphragmatic breathing and relaxed movement) supports the developing life of the self; and prioritizing functional population behaviors (e.g. access to functional health care, economic resources; access to social support) supports the developing life of the society.Principle 5: Health is valued by a system when precision-and-variation generate maintainable-ease of functioning. Health is de-valued by a system when precision or variation prevent maintainable-ease of functioning
By defining precision-and-variation, we can better understand maintainable-ease of functioning in population health:
Functional-Variation generates ease-of-functioning in the present (e.g. fluid and variable motion reflects an ease and variability of one’s movement); while Functional-Precision prioritizes expressions that can maintain ease-of-functioning in the future (e.g. prioritizing challenging exercise for 20 min each day may lead to an ease in bodily movement long term).
Dysfunctional-Variation prevents ease-of-functioning in the present (e.g. prolonged sitting might lead to rigid movement and shallow breathing); while Dysfunctional-Precision might prioritize expressions that prevent ease in the future (e.g. rather than focus on relaxing breathing and movement on work breaks, one decides to drink alcohol to relax).
Without functional-variation, life is fragile and vulnerable to changing conditions of the present. Without functional-precision, life becomes disorganized from the system’s exposure to changing conditions across time. When functional-and-integrated, precision-and-variation value maintainable-ease of functioning in cells, selves, and societies. When dysfunctional or fragmented, precision or variation can de-value maintainable-ease of functioning in cells, selves, or societies. If maintainable-ease of functioning can be valued in cells, selves, and societies, we will likely observe healthy publics.