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  • Writer's pictureEmre Sarı

A Philosophical Journey from Definitions of Health to Measurement Methodologies

Updated: Apr 25, 2019

3/18/2019


1. Introduction


Today, inequality, and especially health inequality subjects are much complex due to the economic, technological, cultural developments of nations, and inevitably globalization. National economies are becoming more international and integrated as cross-border trades with other countries day by day, so the way the world works is changing with this rapidly growing integration (“One World,” 1997). In the introduction part of Health and Inequality (O’Donnell et al., 2015), a book asks the central question for the economists: what is it that inspires economists to think ahead of their scope of expertise concerning social inequalities in health? We know that health is one of the main determinants of well-being as an economic resource, and it helps to measure the quality of human capital (Schultz, 1961). Furthermore, policymakers and public health practitioners aim to increase health conditions of society and decrease health inequalities. Differences in health inequalities are mainly based on factors such as socioeconomic status of individuals, geography, and ethnic backgrounds (Arcaya et al., 2015; Feinstein, 1993). If we look at health inequalities more deeply, we will see that the criticism of inequality and philosophical and public debate about social justice have a central role in the idea of equality (Sachweh, 2017). Unfortunately, most of the researchers in the field of health inequality do not look at its philosophical background (Forbes & Wainwright, 2001) for a better and solid understanding of underlying mechanisms in health inequalities. “Health” and “inequality” concepts are highly crucial issues to discuss, and still there is no definition accepted by everyone for “health inequality” (Carter-pokras, 2002).


Inequalities in health are not just a problem of individuals who have lower socioeconomic status (as measured by education, income, occupation, or locational heterogeneity (Currie, 2009)) (Woodward & Kawachi, 2000), but, it is also a major issue for everyone without considering the different socio economic status. Johnson & Scoeni (2013) say that health is directly related to human capital; additionally, according to growth theory, there is a correlation between initial health status and subsequent economic growth (Barro, 2013). Barro (2013) says that life expectancy is an important contributor of subsequent economic growth; health status, which is a better predictor than educational level, is a key element of life expectancy measurement.


In the long-run, health inequality means the waste of public investments and forces policymakers to increase public spending for maximizing the utility (Maria et al., 2017). As a result, beyond its unfavorable economic outputs, not only does no one benefit from this, everyone also is being harmed due to its negative consequences (Woodward & Kawachi, 2000). Accordingly, we might need to agree on one common understanding of this issue before statistically examining the public health surveys; otherwise, efforts to enhance the health conditions of individuals most probably cause different and in some cases more deeper inequalities. In this regard, the main purpose of this article is first to shed some light on the diverse definitions of health and its inequality and then conduct an empirical work in case of Norway. Based on the annual report from United Nations Development Programme (UNDP, 2018) Norway is among the countries with high levels in terms of health status including infant and adult mortality rate, child malnutrition and life expectancy index, and she is well known with its egalitarianism.[1] Well, does it mean that Norway or other high-developed countries have minor inequalities in health? Unfortunately, beyond the rankings, even judicially they emphasis on reducing health inequalities (Ministry of Health and Care Services, 2012), Norway has substantially more massive health inequalities when compared to the other developed countries’ (Mackenbach, 2012; Strand & Madsen, 2016). Therefore, this issue should be a concern of all nations and encourage policymakers and researchers to develop better understanding and solutions for eliminating health inequalities.


In this journey, we must not forget that existing health inequalities are, above all, the effect of the previous political decisions, collective movements and actions in the societies (McCartney et al., 2013). According to Gainer (2013), there might be an interchange between two different philosophical disciplines, such as egalitarianism and utilitarianism[2], as a merit of policies for social justice.


What about the methodology of measuring inequalities in health? Are commonly used datasets for measuring health inequalities reliable enough to invest both our time and resources in making the health inequality researches and policies according to their results? Those fundamental questions are also helping us examining available sources’ sufficiency for leading us to a meaningful conclusion. If they are insufficient, we can ask for better data sources & methodologies to deeply understand main reasons of health inequalities before looking for better solutions. When we attempt to look at the individual level of inequalities, there is a broad range of measuring methods from subjective measures of health to more objective ones such as medical examinations (Costa-font & Hernández-quevedo, 2012; Johnston et al., 2009). As an example of the subjective measures are such as self-rated health (Nielsen, 2016; Nummela et al., 2007), and quasi-objective indicators of health status (physical functioning score, coronary heart disease, mental health problems, etc.) (Costa-font & Hernández-quevedo, 2012).


Finally, I aim to discuss the philosophical approaches to health and its measurement. These two topics are crucial to an understanding of inequalities in health before fully consolidating academic research to look for a way to eliminate reasons for possible solutions. Current literature is commonly based on articles, which focus directly towards showing differences between individuals and groups in terms of health inequalities, rather than looking for a solution to an already known issue.


2. What is health?


Health is “The state of being free from illness or injury.” (Oxford, n.d.). Can we consider health as freedom from any illness and injury, or should we look for deeper meaning? Is it that simple to reach a conclusion about someone’s health condition? Defining health is crucial for constructing health measures (Ware, 1987). This will help health experts in many fields to a better understanding of current conditions and finding substantial methodologies, results, and early intervention solutions for building more healthy and equal generations.


On 7 April 1948, the World Health Organization (WHO, 2006) extend the meaning of health, and in addition to physical health, their definition takes into consideration of mental health and social well-being. According to Huber et al. (2011), because of its comprehensiveness and passion, this formulation is groundbreaking even though it has limitations; it overcomes the adverse definition of health as an absence of illnesses and injury. Following this extended definition of health, in 1986, WHO declared the Ottawa Charter for Health Promotion and clearly explained the fundamental conditions and resources for health are as follows: [1] peace, [2] shelter, [3] education, [4] food, [5] income, [6] a stable eco-system, [7] sustainable resources, [8] social justice and equity. In the Ottawa Charter, health is also described as a significant source for social, economic and individual development and an essential dimension of the essence of life.


Huber et al. (2011) suggest using the concept of “health, as the ability to adapt and to self manage” for identifying and characterizing the WHO’s definition of health. They focus on the three areas of health: physical, mental and social. On the other hand, Ware (1987) supports that at least five health concepts measurement is necessary to achieve the broadness inherent in the definitions of health. In addition to the previous ones, he also adds role functioning and general well-being.


1.1 Physical Health

In the physical health approach, the main determinants are physical limitations, abilities, and well-being. Here we should consider individuals physical conditions such as their performance of self-care, mobility, and daily activities (Ware, 1987). For example, when you wake up in mornings, do you need help for getting out of the bed by yourself, or are you able to walk from your home to closest bus stop? Let us improve the situation a little bit more; an individual who has an average life and moderately doing his/her daily physical activities, is this individual able to join his/her company’s basketball team just for fun? Finally, another important consideration is the assessment of the individual's physical health status by itself. In some cases, it is crucial for individuals to assess their physical condition to determine if there is any disease. Huber et al. (2011) defines this approach with the capability of “allostasis – the maintenance of physiological homeostasis through changing circumstances.”


1.2 Mental Health

According to Veit & Ware's (1983) five-factor structure of mental health inventory, which we can divide into two fundamental groups including psychological distress and psychological well-being. Anxiety, depression, and loss of behavioral/emotional control are the sub-elements of distress; while general positive affect and emotional ties are categorized under well-being group. On this count, cognitive dysfunction which results from elements of psychological distress and psychological well-being could be symptoms of possible illnesses (Ware, 1987). For instance forgetting frequently; feeling confused - hallucinations; or doing more mistakes than usual.


1.3 Social Health

Here, an individual’s social ties with society come into prominences, such as interpersonal contacts and social resources. Today, most of the cohort and longitudinal health studies are also looking for the social health status of individuals (The Tromsø Study 6, 2008; The Tromsø Study 7, 2016). For example, “Do you have enough friends who can give you help and support when you need it?” or “How often do you normally take part in organised gatherings, e.g. sports clubs, political meetings, religious or other associations?”


1.4 Role Functioning

Each of us has daily roles and responsibilities, which varies from one person to the other. While some of us have to go to work or school, some need to stay at home to look after the children. However, whatever happens, we all have a daily role and responsibility regardless of whether it is essential or not. The limitations in the role represent the lack of capability to achieve daily physical goals (Ware, 1987).


1.5 General Health Concept

SRH is a fundamental source of general health concept. It represents a source of significant data on health status and helps to predict mortality in longitudinal studies (Idler Ellen L & Benyamini, 1997). We can give these questions as examples “What is your current state of health?” or “Do you get pain or discomfort in the chest even if you are resting?” (The Tromsø Study 5, 1995).


Boorse (1977) defines health as a normal functioning, “where the normality is statistical and the functions biological.” (p. 542). After thirty years later, Sen (1993) introduces us his ‘capability approach,’ “The capability approach to a person’s advantage is concerned with evaluating it in terms of his or her actual ability to achieve various valuable functionings as a part of living.” (p. 30). He differs his theory from other approaches; equality basis resources like Dworkin’s criterion of ‘equality of resources’, assessments of negative freedoms which focuses on procedural fulfilment of libertarian rights and rules, comparisons of means of freedom like the Rawlsian theory of justice, opulence which focuses on commodities, and personal utility as a pleasure and happiness of individual. In other respects, Nussbaum (1993) brings the Aristotelian arguments “that is, respond to the claims of human need, the strivings towards the good, the frustrations of human capability, that this situation displays to the reflective person.” (p. 19).


Nussbaum (2003) supports the Sen’s ‘capability approach’ in the context of the theory of social justice. Nevertheless, she objects to his ‘perspective of freedom’ because of broad meaning of freedom comprise everything, according to her examples, some freedoms can be trivial, some of them might be good or bad, some of them are important, and every freedom limits the other. In addition to this, she is asking for clear and solid definitions of capabilities from Amartya Sen. On the contrary, Sen (2004) stand up for his approach and refusing the publish a list of capabilities like Nussbaum’s ten ‘Central Human Capabilities’ (Coast et al., 2008). He is clarifying his idea with three justification; [1] He is arguing that the capability has different purposes in his approach, [2] social conditions and their priorities may vary, [3] even in the current social context public debate and argumentation can lead to a broader conclusion of the role, access, and importance of particular capabilities.


Capability approach does not look for individuals preferences for evaluating their abilities; those individuals might have been adapted to their current situations and not aware of their lack of capabilities (Coast et al., 2008). Coast et al. (2008) also discuss the relationship maximization, welfarism, and the capability approach. Most importantly, they strongly suggest taking into consideration of the capability approach for health economists because of its ethical intricacies, theoretical and empirical inconsistencies and the implications of value judgments. According to their opinion, it will help to develop a more comprehensible health economics discipline, more solidly indoctrinated in societies’ values.


3. What is health inequality?


Health inequality is both a dimensional concept that is referring to measurable quantities and political concept that shows moral responsibility to social justice (Kawachi & Subramanian, 2002). I will discuss the measure of health inequality in the following section, but here, my focus is based on its conceptual background. The word of inequality has more or less the same meaning in our personal vocabulary, and it refers to social injustice. On the other hand, the idea of justice makes the much more laborious and complicated to find common ground for defining the simple and straightforward meaning of health inequalities. For example, Carter-porkars (2010) share 11 different definitions of “health disparities,” which are commonly used in the USA. In addition to them, Kawachi & Subramanian (2002) define it as “Health inequality is the generic term used to designate differences, variations, and disparities in the health achievements of individuals and groups.” Even dictionaries, such as Cambridge and Oxford, have differences; while Cambridge (Cambridge, 2019) focuses on opportunity injustice, Oxford (Oxford, 2019) mentions the difference in circumstances. Carter-porkars (2010) also informs us that there is no unity regarding the usage of the terms and their definitions, “inequity,” “inequality,” and “disparity.”


Health-related lifestyle can vary depending on the country, geographical conditions, different socioeconomic levels, gender, age groups, etc. Related to those fundamental differences, the sources of social inequality in health also have a variety of possible underline mechanisms. In the egalitarian perspective, luck egalitarianism[3] is one of the major philosophical approaches to define what unavoidable is and what unfair is. According to Andersen et al. (2013), luck egalitarianism is “unjust for a person to be worse off than others through no choice or fault of her own.” In other words, if a person suffers from inequality because of her personal choices, we cannot say that this is unfair.


On the other hand, Anderson's (1999) paper defend ‘democratic equality’ against luck egalitarianism. She argues that luck egalitarianism is not enough to meet the fundamentals of egalitarian theory, such as “equal respect and concern for all citizens.” On top of this debate, Whitehead (1991) makes clear the differences between unavoidable and unfair health circumstances in general content. According to her study, we can mainly identify health differences with seven determinants and take into consideration the last four categories as unjust.


· Biological diversity.

· Personal choices which can damage your health (like high volume & intensity weight training)

· The temporary health advantage of a group, which adopts a health-promoting behavior before, compared to the other (as long as other groups can catch up very soon).

· Severely restricted lifestyle selection in which affects health.

· Having unhealthy, stressful working and living environment.

· Deficient sources for helping everyone to reach fundamental public and health services.

· Social mobility in health, which involves the tendency to move to a lower social scale for sick people.


At this very point, thanks to George (2010) for being remembered that Jean J. Rousseau’s (1754) words about the main sources of inequality: nature and society.


I conceive that there are two kinds of inequality among the human species; one, which I call natural or physical, because it is established by nature, and consists in a difference of age, health, bodily strength, and the qualities of the mind or of the soul; and another, which may be called moral or political inequality, because it depends on convention, and is established, or at least authorised, by the consent of men. (p. 12)

Utilitarian theories, consequentialist[4] and communitarian[5] approach focus on decision, accomplishment and community benefits, rather than health itself (Ruger, 2004). According to Baker & Strosberg (1992), utilitarian views of triage is based on to save the most salvable patients rather than using the sources for everyone’s good. In this vein, Le Grand (1987) explains the utilitarian approach against health inequalities. He says that utilitarian distributions are equitable, and those distributions are already egalitarian in nature. Focusing on maximizing utility and he tries to explain how utility is distributed among two groups of people; namely, poor and rich individuals. He concludes that redistributing health-promoting resources could lead to sustainable and effective utility.


Consequently, we need to have transdisciplinary approaches rather than traditional mono-disciplinary perspective because today we live in a world different from the 1990s; the world is no longer in the same world. The interdisciplinary approach helps researchers from different disciplines to understand underlining mechanisms of health inequalities.


4. What is the Measurement of Health?


According to Stevens' (p. 677, 1946) article measurement “is defined as the assignment of numerals to objects or events according to rules. The fact that numerals can be assigned under different rules leads to different kinds of scales and different kinds of measurement.” Despite the fact that 70 years have passed over his article, we are still using the same scales today, such as nominal, ordinal, interval, and ratio.

Stevens (1946) defines the nominal scale as a primitive form of measurement scales and uses as labels or numbers’ of something, etc. The ordinal scales are widely used in educational and socioeconomic levels, and rehabilitation (Merbitz et al., 1989), etc. Merbitz et al. (1989) discuss the statistical misinference of the ordinal scaling system because of its lack of representing ‘how many more’ and yes, we know which one is greater or less than other; but when we need to understand the distance between two scores, it does not satisfy the needs. For example, “How is your health compared to others in your age?” (The Tromsø Study 6, 2008). The question is asking to point yourself according to others from much better (1) to much worse (5). Therefore, we know the current situation like it is ‘much better’ or ‘much worse,’ but we cannot know how much better or worse.


For more in-depth understanding the answer of a participant of the survey, it might be asked to rate his/her opinion about his/her current health condition compared to others from 0 (much better) to 10 (much worse). That would be the interval scale and in this way, we had a chance measure distance the participant’s answer, and the arithmetic mean. Of course, zero does not represent the absence of health, and it is an arbitrary zero on this scale. Like Stevens's (1946) example of measuring the temperature with Centigrade and Fahrenheit explain the temperature differences between 13 Celsius and 26 Celsius, but we cannot say that 26 Celsius is more than two times of 13 Celsius. Because in here, also we do not have actual zero to achieve this conclusion. The same problem also exists in the Gregorian calendar, because we do not have zero in our calendars, which represents the absence of history.


On the other hand, Kelvin’s Thermodynamic Temperature Scale defines absolute temperature, and it has meaningful zero because it means that there is no heat at zero points (Enedict & Xvi, 1984). In Ratio Scale, absolute meaning of numeric figures, when someone gets zero from an exam it means absolute emptiness or meaningless; or lets thing about the age, we can consider zero as representative of an unbegotten child. For example, we bought four pomegranates and five mandarins from the greengrocer. While counting how many things we bought, we used cardinal numbers, and those are the basics of ratio scale (S. S. Stevens, 1946).


The measurement instruments of health should be capable of differentiating between the general health status of populations and individuals, and also we need those instruments to understand the differences between subjective and objective health indicators (Huber et al., 2011). Economists’ approach to the measurement of health starts with two different methods, such as ordinal utility and cardinal utility (Fishburn, 1989). In general, the utility theory takes into consideration of individuals’ level of satisfaction or pleasure, and this approach is a version of utilitarianism theory (Posner, 1979). Sidgwick (1901) defines the term of ‘utilitarianism’ as “the greatest possible surplus of pleasure over pain: with equal amounts of pain and pleasure conceived as canceling one another out for purposes of ethical calculation.” (p. 201). In the economics literature, ‘utilitarianism’ evolves to utility functions. Neoclassical-economists use a cardinal utility function in behavioral economics to maximize the utility of individuals. The cardinal function uses an interval scale and independent from modality of items (Kornienko et al., 2013), and at this very point, it is good to remember of measurement example of temperature. Like measuring the temperature with Celsius, zero does not represent nothingness; we can use ‘zero’ arbitrarily in our measurements. According to Strotz (1953), the ordinal utility function came to like the principle of Occam’s Razor; the utility was then considered something ordinal, and it was not subject to measurement but subject to ranking. It looks for utility maximization under individuals’ capability constraints.


Choosing one of the utility functions or derived versions while measuring health is a still big debate among economists. Both functions have pros and cons; Morreau (2014) also emphases that if choose to cardinal information, we might have a chance to have ordinal information even it is precise or imprecise. In his next article (2015), he is discussing between Thomas Kuhn’s problem of theory choice and Kenneth Arrow’s social choice theory. According to him, one of the problems is “how well individual theories measure up.” (p. 241). In this regard, I suggest clarifying the problem about health first; because as a researcher, no matter how we seek to objectiveness in our health datasets in some cases we might need a subjective opinion of individuals like self-rated health.


5. Conclusion


In recent decades, the number of published studies in health economic has increased considerably (Decimoni et al., 2018). The growing interest in this strand of literature is due to multi-disciplinary nature of health economics as health performance and economic performance are interlinked both at micro and macro level (Edwards et al., 2013; Panda & Thakur, 2016). This means that the interplay between causes and consequences of health and economics status are rooted in other fields of social science such as politics, law, philosophy, demographics and anthropology (ALLEA & FEAM, 2018). Hence, studying health economics holds special interest for researchers in wide range of areas.


A large number of studies in health economics concluded that wealthier countries have healthier populations to contribute to the economy (Bloom & Canning, 2008; Stevens et al., 2015; Suhrcke et al., 2006). On the other hand, poverty and poor healthcare, mainly through infant malnourishment and mortality, adversely affects life expectancy and this, ultimately hinders performance of the economy. This means that poverty/well-being is both a cause and a consequence of poor/good health.


In this paper, I discussed the definition of health and measurement methodologies according to current literature. However, despite the presence of abundant literature in this field, definition of ‘health’ is still controversial among the researchers. In fact, this controversy is expected as researchers with different fields of expertise investigate their relevant research question from different perspectives. Furthermore, they might have conflicting interest and congruent objective. While economists aim to maximize social welfare, philosophers with the main focus on ethics, attempt to minimize the gap in the health status and health inequality of different population groups. Hence, prior to conduct an empirical work on health economics, we need to find a clear definition of “health and the corresponding inequality”.


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[1] Egalitarianism, “the doctrine that all people are equal and deserve equal rights and opportunities.”


[2] Utilitarianism, “the doctrine that actions are right if they are useful or for the benefit of a majority.” https://en.oxforddictionaries.com/definition/utilitarianism


[3] Luck egalitarianism, “justice demands that variations in how well off people are should be wholly determined by the responsible choices people make and not to differences in their unchosen circumstances.” https://en.wikipedia.org/wiki/Luck_egalitarianism#cite_ref-1


[4] Consequentialism, “the doctrine that the morality of an action is to be judged solely by its consequences.” https://en.oxforddictionaries.com/definition/consequentialism


[5] Communitarianism, “A theory or system of social organization based on small self-governing communities.” https://en.oxforddictionaries.com/definition/communitarianism

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