What is health?

What is health?

According to the World Health Organization (WHO), ‘the enjoyment of the highest attainable standard of health is one of the fundamental rights of every

human being.’ 1 As Sen observes, ‘health is among the most important conditions of human life and a critically significant constituent of human capabilities which we have reason to value’ (2002, p660). In addition to its intrinsic value, it is also agreed that health is instrumental to economic growth, educational achievements and cognitive development, employment opportunities, income earning potential, as well as the more amorphous aspects of dignity, safety, secu- rity and empowerment. But what is health? According to the constitutional preamble of the WHO (1946), ‘health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ 2 Although holistic and indisputable, this definition is far from operational. All too often, we rely on a common set of readily-available variables to proxy health more broadly. At a population level, the conventional indicators adopted are infant mortality rate or life expectancy (which is derived from demographic models using age-standardized death rates of a particular cohort, with expected variations). While life expectancy and mortality are undoubtedly important, they do not adequately convey aspects related to the ‘quality’ of life. For exam- ple, an individual can be alive while living with an unbearably painful disease, which leaves her bed-ridden and unable to function to her fullest capacities.

Similarly, many economists resort to measures of anthropometry to proxy health, that is, the measure of height-for-age, weight-for-height or body-mass- index (BMI). While such measures are meant to convey aspects of nutritional deficiency and/or over-nutrition, they are general proxies that fail to convey

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precise micronutrient circumstances. Moreover, the standards that are used to draw cut-offs – similar to poverty lines to indicate over- or under-nutrition –

are highly contested in the international literature. 3 Nevertheless, while nutritional circumstances may have contributed to current anthropometries (i.e. measures of an individual’s height and weight for their given age and gender), they do not necessarily reflect a poor quality of life. Does an individual who is exceptionally short for their age (i.e. stunted) have fewer opportunities or a compromised intellectual capacity? It is assumed that an individual who is stunted has become that way because of nutritional deprivations that also have an effect on cognitive development, educational attendance and subsequent opportunities and potential. However, despite the obvious correlations, such assertions merit further scientific scrutiny since there is considerable debate within the medical and psychological literature on such causal relationships.

What is important here is that the measures we often use for health convey

a very limited aspect of health. Moreover, if we were to consider health from the perspective of the human development and capability approach, we would consider what matters most to individuals concerned and not what researchers or policy-makers deem to be most relevant.

If, as is often the case, we use infant mortality as a measure of population health and the utility which we seek to maximize, we could focus on the factors that most effectively prevent infant deaths. Our resource inputs would include an arsenal of vaccinations, trained birth attendants, oral-rehydration therapy or even baby formula. We would fail to see how such inputs get converted to a set of capabilities that people themselves value. What are the contextual, individual or cultural factors that intervene?

Similarly, if we decide that a reduction in stunting is most necessary for improving the health of a population, we would naturally focus on maximizing food inputs – especially protein, which is particularly relevant for linear growth (i.e. height). However, does that input necessarily get translated into health or the capability to achieve health? If not, why not? This chapter argues that, by failing to account for relevant conversion factors and by disregarding individual choices and constraints, we may not, in actuality, be efficient in our efforts to improve health.

In addition, it is important to recognize that health is multi-dimensional, and individuals make choices between and within these dimensions every day. For example, an individual may choose to live a short but full life rather than suffer from a painful and debilitating, but non-lethal, disease. Or, they may choose to risk a heart disease for the pleasures of a rich diet.

Conventional approaches to health