What Is Health For?

In a world of overtreatment, overtesting, flawed research, and non-evidence-based medicine, it sometimes feels like we’re wasting our time at Sensible Medicine. Then we get a submission like this one, and I think there are people out there who really get it.

Adam Cifu

We talk a lot about how to be healthy.

But what does that mean? Is a healthy person someone without any illnesses? Someone who doesn’t take any medications? Someone whose blood pressure, cholesterol, weight, glucose, sleep, mood, and bowel movements are normal?

Or have we gotten so good at measuring health that we have started to confuse the measurements with the thing itself?

Medicine spends a lot of time telling people who feel healthy that they really aren’t. That sounds like a bad thing, but it isn’t always. A blood pressure of 190/110 isn’t suddenly fine just because the patient says they feel great. Neither is an A1C of 11. That early cancer? You’ll probably never feel it. That is the point of preventive medicine: finding trouble before it feels like trouble.

So feeling good alone cannot be the definition of health. But is the opposite — a body with nothing wrong with it — any better a definition?

I care for patients in their seventies who take a handful of medications, have arthritis in several inconvenient places, and consider themselves generally healthy. Their knees may hurt when they stand up. They know which chair is easiest to get out of. They keep ibuprofen in the truck. But they still hunt, travel, work in the garden, and help with grandchildren.

They don't necessarily see these things as contradictions. The knee can be bad, and the person can be healthy. Both things can apparently be true at once.

I also see younger patients with normal labs, normal imaging, normal vital signs, and a growing conviction that we simply have not yet ordered the right test to find what ails them.

Who is healthier?

We can measure a great deal about both of them. What those measurements can’t tell me is whether their bodies still let them do the things that matter.

Give me enough blood tests and imaging procedures, and I can find something wrong with you. A lab value outside the normal range. A thyroid nodule. A bulging disc. A few premature heartbeats. Human bodies are wonderfully uncooperative with our preference for tidy categories.

That is not an argument against looking when it matters. It is an argument against mistaking every finding for a verdict.

The same is true of symptoms. Bodies are not quiet things. They ache, occasionally creak, and get tired. A forty-year-old body certainly doesn’t feel like a twenty-year-old body. I assume this trend continues.

When did we decide all of this meant we weren’t healthy?

I work in an emergency department and in my own medical practice. I have watched people arrive unable to breathe. I have told people that the scan showed cancer. I have cared for people whose bodies suddenly no longer let them do the things they want to do.

Then I go home.

At home, I have nights when I wake at 3 a.m. and cannot get back to sleep. I have weeks when running feels easy and weeks when I look at my shoes by the door and decide it’s something better left for tomorrow. I am sure there is a sleep score or VO₂ max I could improve if I measured it.

But most of the time, I choose not to.

I can work. I can walk, hike, and run. I can think and travel. I can paint my bedroom, dig a new garden bed, and get through a twelve-hour shift on my feet. For the most part, my body does what I ask of it. I have come to think that this is a bigger part of health than we acknowledge. A healthy body doesn’t have to be perfect. It has to let you live your life. Working in medicine has made me more convinced of this, not less. I spend enough time around illness to know there is a difference between something being wrong with your body and your body just being a body.

Of course, function alone isn’t enough. Disease does not always have the courtesy to make itself known. The man with severe hypertension might feel wonderful right up until he doesn’t. We would be pretty lousy at practicing medicine if we waited for every disease to announce itself. But the ability to actually live your life ought to count for more in our definition of health than it currently does.

When I ask patients what they want from their health, nobody tells me their life’s ambition is an LDL of 68. They want to keep hunting. They want the stamina to travel. They want to get on the floor with their grandchildren — and get back up. They want another decade on the farm.

That is why the numbers do matter. An LDL value matters because lowering it might prevent something and, therefore, allow someone to keep doing something they love. The number should serve the patient. We are not supposed to spend our lives serving the number.

And there is always a better number.

An LDL of 130 can become 100. A hundred can become 70. Seventy can become 55. Blood pressure can almost always be a little lower. You can always lose a few more pounds. Exercise more. There is almost always some risk left to reduce.

Medicine has plenty of thresholds for when something becomes a problem. We have remarkably few for when someone is healthy enough.

Maybe the question at an annual visit shouldn’t only be, “What risks can we reduce?” but also, “What are we trying to preserve?” At some point you have to wonder what all this health is being saved for. I don’t know that I can give health a clean definition. I’m starting to get a bit suspicious of anyone who can. But I know it has to leave room for imperfection. Otherwise none of us will qualify as healthy for very long.

The purpose of health cannot be to spend our lives pursuing health. At some point, the body has to be good enough that we can go use it.

Kirsten Balin, FNP, is a family nurse practitioner who works in emergency medicine and owns a medical practice in rural Oregon. She writes about medicine, health, and the increasingly complicated boundary between being sick and simply being human at Differential Notes.

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