At a time when conventional and complementary medicine are jostling for position within a new pluralistic medical marketplace, there are risks that some of the more interesting, subtle and different aspects of complementary medicine may be lost or ignored. This would happen if complementary medicine is viewed as simply a group of useful additional techniques to be subsumed into the current paradigm of medicine. In this paper I would like to point out that many of the fundamental concepts of complementary medicine are radically different from conventional medicine. I would like to do so by focusing on that most problematic of all concepts in medicine; the nature of health itself. In an ultimate sense, health is invisible. It is always defined by its signs which point somewhere to the mystery of health itself. But in practice, all medicine requires working definitions of health as its basis.
The Conventional Perspectives on Health
Within conventional medicine there are three separate kinds of health definition: the practical/medical, the utopian, and the social. The practical/medical is that found in medical texts and that which medical students learn in university. A healthy person is symptom-free. A symptom is defined as an abnormality recognisable by professionals. They are not necessarily connected to the patient¹s subjective experiences of illness. For example a patient with non-specific discomfort and malaise, may be undiagnosable and may therefore remain untreated. This happened with the so-called post viral syndrome (M.E. or Myalgic Encephalomyelitis). Patients were not recognised as having a legitimate disease until they mounted an international public campaign to have their disease named and recognised. Only then could it be taken seriously in treatment and research. There has been a long critique of this biomedical description of health, beginning with Illich 1 . It points out that the pathological and mechanistic bias creates a medicine that can damage health while treating disease. The root cause, in my view, is a radical blindness concerning the nature of health itself. To be fair, it must be said that there are many individual professionals, especially those at the fringes of modern medicine, such as nurses and physiotherapists who do have a strong feel for the nature of health. However this is often in spite of the current medical view, rather than because of it.
The utopian model goes beyond this. It is typified by the definition arrived at by the World Health Organisation in its 1977 conference at Alma Ata: ³A state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity². It is an ultimate definition of health, determining it as the fulfillment of the human potential. However it is of limited usefulness, because modern medicine does not have the tools nor the ability to serve the human potential. There are no well-being medicines in the pharmacopoeia.
The social model is that developed by medical sociology, and pioneered by Antonovsky and others 2 . It has origins in the systems theory and in views of social conditioning. It states that health is a result of appropriate social adaptation and harmony. It is society as a whole that moves towards health or sickness by its sanction of Œsalutogenic¹ or disease-oriented behaviours. It is closely linked to the risk factor approach to health. The social model of health is as mechanistic as other conventional models, but it does break the pathological bias.
The Folk Depiction of Health
A further perspective is that based on common sense and life experience, and it is embedded in folk culture and ordinary language. Here health is one of those terms which run right across cultural and individual consciousness like 'goodness', 'life', or 'rightness'. Everyone will define it in a different way, according to cultural norms. For example someone who has chronic pain will define health as a pain-free period. In the modern fitness movement, health will be defined as physical performance. However in traditional village cultures, health is often defined as peaceful undisturbed existence. European culture has defined both fatness and thinness as healty at various times in its history. Ancient Greece viewed health as perfect bodily proportions. The American Indians viewed it as endurance to physical strain. In China health is regarded as equivalent to longevity, by definition. In India health is regarded as the luster of the skin and the shine in the eyes. All of these perspectives are partial signs of health, none is all inclusive. Such common-sense views of health change all he time and are a reflection of present-time experience. Since they are changing, and they reflect human function and well-being rather than symptoms, the folk views are closer to those of complementary rather than conventional medicine.
The Well-being and Autonomy Perspective
The well-being movement arose in the United States as a response to the extreme reductionist position of technical medicine. It defined health as feeling good, performing well, being fit and on top of the world. It expressed an interest in the psychosomatic origins of disease, but transcended it to embrace the psychosomatic origins of health. Health is a result of consciousness, of positive thinking, of affirmation. Health is achievable by mind-body techniques, such as meditation, relaxation, dance, massage, vitamins and having a good holistic physician at your disposal 3. The perspective here is individualistic, stressing personal responsibility and freedom. The late Norman Cousins discussed this approach in his personal journey to health, and described health itself as such a personal odyssey, a process of fulfilment, of becoming what you truly are 4 . To which Antonovsky, representing the social view of health, has commented that it is all very well if you can afford it. This is a strongly psychological view, influenced by studies of cancer patients who partially or completely cured themselves. Such patients seem to get better by individualistic health promoting attitudes and practices, rather than by therapy. Psychological treatments and psychotherapy which started with the question: 'what is wrong with this person, and how did she or he get this way?' were less effective than asking: 'what is right with this person, what are her or his unique strengths, enthusiasm, and zest for life? 5 . This definition of health mentions the Will To Live, inner development, involvement and engagement in life, autonomy, a conviction that life has meaning, and good social connections 6 . These qualities reveal what in Jungian terms might be described as individuation becoming a full person.
The Alternative Perspective
Health within alternative medicine is drawn from a tradition which is far more ancient than that of conventional medicine. Because of that it does not need to formulate its perspectives on health with biomedicine in mind, either in accord with it or in opposition to it. Thus it would view the symptom-based definition of health of biomedicine, the function-based definition of the WHO, the fitness-based definition of the well-being movement, the autonomy-based definitions of the psychological movement, and the systems theories of the salutogenic movement as partial and limited. It would draw on all of these as needed, but transcends them all. It is much more vitalistic and life oriented, without the need to constrain itself into western mechanistic, reductionist models of how the human being functions. The definitions of health arise from the main themes of alternative medicine. Here are some themes within complementary medicine which move in an opposite direction to conventional paradigms. A fuller analysis of such concepts will be found in the Handbook of Complementary Medicine 7 : 1. Self-Healing is Paramount . The in-built natural healing process is respected and recruited during treatment, although it is not necessarily understood. Particularly in Oriental and Ayurvedic medicine, a considerable proportion of traditional practice is devoted to the restoration of vital force, resistance and self-healing energy. In Western herbal medicine there is very frequent use of a category of herbs called 'alternatives' or 'blood purifiers', to achieve this purpose such as cleavers ( Gallium aparine ), burdock ( Arctium lappa ), sage ( Salvia spp) and myrrh ( Commiphora mol-mol ).
2. Working with, not against, Symptoms . Symptoms are a guide in the journey to a cure. They are managed, not suppressed. For example the daily ebb and flow in severity, frequency, type and location of a symptom such as headache may be used by an acupuncturist or homeopath as a guide to the course of treatment of deeper problems with organ function. A migraine-type headache could be seen by an acupuncturist as arising from overactive liver metabolism (liver Œfire¹ rising). Real treatment involves an adjustment to the propensity of the liver to create inflammation, not merely relief of symptoms by analgesia.
3. Individuality . Each person¹s condition is different, has arisen from different reasons, against a different constitutional background, and requires a different path for treatment. Decisions are personal and individualistic, not statistical. One of the indications of the richness of any medical system is the development of a typology with which individual differences in health, disease and response to the environment can be understood. The constitutional picture in Ayurvedic medicine is a particularly developed art, which integrates thousands of characteristics of body, skin, personality, habits, etc. This establishes an individual¹s susceptibilities, strengths and weaknesses, and guides both prevention and treatment.
4. Integration of Human Facets . There is less a priori division between Mind-Body-Spirit or Environment-Society-Individual. In homeopathy and Oriental medicine, for example, emotional, psychological and behavioural signs are always included seamlessly with physical signs in diagnosis. This is rather less so in naturopathy, herbalism and the manual therapies, but even here holism is often applied as an approach of an individual practitioner.
5. Beginning or Ending of Treatment Defined Contextually. There is less predetermined definition of state of illness where treatment must begin and wellness where treatment must end. One patient may require assistance to reach a state of well-being and accommodation to his cancer. Treatment will finish when this is achieved, although in conventional terms he is still seriously ill. Conversely, another client may seek to improve his energetic balance. Treatment in this case, in conventional terms, is of a healthy person.
6. Conformity to Universal Principles. Remedies are discovered and employed in conformity to patterns of relationships (such as yin/yang) between all living creatures and their environment. These patterns are often subtle and involve energetic rather than material phenomena. For example Ch¹i in Chinese medicine is a tangible but invisible vital force which operates continually as the basis of all function. In Oriental medicine it is sensed and utilised in much the same way that modern man would sense and also utilise gravity. Despite the fact that Ch¹i is so universal, it is enormously elaborated as an explanatory principle to describe detailed changes in function, e.g. constrained, stagnant, wild, deficient, excess, etc. of liver, spleen, kidney, etc. described earlier.
Considering these themes will demonstrate the inclusive yet pragmatic definitions of health implied within them. For example, health in Oriental medicine involves a harmonious relationship with all the energies and influences within which man is immersed. These include but are not limited to material, natural, environmental and social influences. But it also implies having a good constitutional and genetic basis, termed 'inherited energy'. In addition, it is recognised that health is a mind-body-heart issue, without acknowledging any boundaries between them. Oriental medicine and some major complementary medical systems never passed a Cartesian phase, so there is no need to postulate or evoke concepts like psychosomatic. These are qualities observed naturally within the mind-body-heart continuum, expressed as the total energetic body of man. Such health concepts can also legitimise a more spiritual sense of the nature of health and healing, for example that arising from a Buddhist perspective: 'If there is a single definition of healing, it is to enter with mercy and awareness those pains, mental and physical, from which we have withdrawn in judgement and dismay.' 8
Since conventional medicine has drawn a line at the symptom boundary it also lacks an operational language to assess health itself. The various states of health are describable only in common language (e.g. 'well-adjusted', 'vital', 'energetic', 'glowing') even by doctors. Whereas in alternative medicine the practitioner is able to call on a rich qualitative language to describe subtle states of health, and to differentiate these different states of health by diagnostic signs. For example in Oriental medicine the practitioner determines the flow of energy and materials through organs and the functioning of the main organ systems. He may ascertain that an organ is too 'full' or 'empty', 'hot' or 'cool', etc. The quality of the 'chi' or vitality of the organ systems may be stuck or scattered, rising or falling, or balanced, spread in the right way around the body, full, resistant, etc. In herbalism and naturopathy health can be described as the balance between elements and fluids.
The definitions of health employed in alternative medicine have as their philosophical basis a greater respect for what is 'natural', meaning unfabricated and less manipulated according to transient human intentions. This goes with a strong vitalism. This life-orientation necessarily implies a greater sense of the unknown and respect that goes with it. This leads directly to the lack of strong interventions that characterizes alternative medicine compared to conventional medicine, and the greater trust of self-healing capacities even if they cannot be understood.
Some Characteristics of Health Arising from the Vitalistic World View of Alternative Medicine
It is not easy to give one formula describing health within the various alternative medical systems. However some features of health that are common can be listed. They give the flavour of the definitions of health implicit within the alternative techniques and traditions:
Implications of Alternative Descriptions of Health on Health Care
We are not getting more healthy today despite a massive and crippling investment in health services. Though life expectancy has risen, largely because of the drop in infant mortality, US statistics show a steady rise in ill-health: from an average of 0.82 episodes of disabling illness a year in 1920 to 2.12 in 1988 9 . This is the age of 'the vertically ill'. Evidently something has gone wrong. Here I propose that the limitations of the biomedical model are inherent in its definition of health. This definition, though largely implicit and unconscious, nevertheless informs everything that is carried on in the name of medicine. For example the clarity with which acute sickness can be defined as ill-health compared to chronic and early stage degenerative conditions has resulted in huge numbers of degenerative conditions (e.g. atherosclerosis) which, as the death certificates show, are largely untreated and untreatable.
Scientists and health professionals could learn a great deal from alternative medicine about defining and measuring health. Health care today would benefit from an awareness of more meaningful ways of describing and measuring health offered by alternative medicine, for example by including constitution and the quality of vitality. It could also provide a rich source of ideas and criteria for assessment of health. For example the question whether lowering cholesterol contributes to overall health has been tested using billions of dollars of research money and many years of investigation, yet the question is still not finally decided, and official advice on this question remains ambiguous. If more appropriate assessments of health were used it would be much easier to ascertain what is healthy and what is not, for each person, and design appropriate ways of assessment of therapeutic interventions. Alternative medicine is rapidly increasing in popularity. As its conceptual basis is prior to, and in many respects opposite to, conventional medicine, it provides a challenge to it which has not yet been accepted. Alternative medicine¹s concentration on healing the healthy as well as the sick, and its familiarity with the origins of disease on the ground of human life, give it special skills at understanding states of health. It sees health as a process which is intricately related to the way a constitution and personality develops through time within the matrix of all the influences and relationships that are experienced.
REFERENCES
1. Illich, I. (1976). Limits to Medicine, Harmondsworth. Penguin. Engel, G.L. (1977). The need for a new medical model: a challenge for biomedicine . Science, 196:129-36.
2. Antonovsky, A. (1981). Health, Stress and Coping, San Francisco. Jossey-Bass; Antonovsky, A. (1994) A social critique of the 'well-being movement'. Advances, 10: 6-12.
3. Dossey, L. (1982). Space, Time and Medicine, Boulder. Shambala.
4. Cousins, N. (1979) The Anatomy of an Illness as Perceived by the Patient, New York. Norton.
5. LeShan, L. (1979) Cancer as a Turning Point, New York. Dutton.
6. Sheehy, G. (1985) Pathfinders, New York. Bantam; Rijke, R. (1993) Health in medical science In: Lafaille, R. and Fulder, S.J. Towards a New Science of Health. London. Routledge.
7. Fulder, S. (1996) The Handbook of Complementary Medicine, Oxford. Oxford University Press.
8. Levine, S. (1997) A Year To Live, London. Thorsons, Harper Collins.
9. Barsky, A. (1988). The paradox of health . New England Journal of Medicine, February 18, 414-8.
Stephen Fulder is the Director of Consultancy and Research on Biomedicine (CAROB).
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