Health as a Means, Not an End: A Public Health of Consequence, May 2019

Health is a means, not an end. In some respects, such a statement may be at odds with a health journal read by professionals who commit their time to studying or working on how best to promote health. It is not surprising if we mistake our goal, health, as the end of our effort. But, we argue, health should not be the end at all. Health should be the means through which all persons can live full and rich lives. By way of analogy, although we may spend time making sure that our car works, we do so to get us from point A to point B. Our car is the means, the journey and the destination themselves being the end. Put a bit more eloquently, the 1946 preamble to the World Health Organization constitution recognizes health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”^1(p981) Appreciating health as a state of well-being means that we value its role in paving the way to living life as we wish, without encumbrance.

A BROADER LENS

Why do we engage with this framing? It is because, we suggest, thinking of health as a means instead of an end has (at least) three major and important implications for what we do collectively in public health.

First, when we think of health as a means instead of an end, our focus shifts from prolonging life at all costs to maximizing our quality of life with the aspiration for all of us to “die healthy.”² This is, to no small degree, counter to the dominant national narrative on health, which increasingly involves unfettered boosterism of efforts to prolong life indefinitely. Once the stuff of science fiction, serious thinkers have engaged in the notion that we can achieve immortality,³ even as substantial science shows that there is likely a natural end to the human lifespan.⁴ This approach, however, diverts attention away from investment in creating a healthy life for its duration. This is well exemplified by the rise in so-called diseases of despair over the past few years.⁵

The article by Gaydosh et al. (p. 774) in this issue of AJPH adds further evidence to this set of concerns. Using data from the National Longitudinal Study of Adolescent to Adult Health, the authors show a rise in despair generally across the country and correctly note that this can presage rising mortality. It seems to us that attention to why we have an increase in despair, including the social and economic conditions that contribute to it, would follow naturally from an appreciation of health as a means, not an end. We would benefit from clarity of focus on the forces that result in poorer lives lived to the end of creating the conditions in which the largest number of people can realize their potential.

Second, a focus on health as a means instead of an end can help sharpen our science and scholarship; in other words, it can guide the questions we ask, the insight we are looking for. We thought this was well exemplified in the article by Wang et al. (p. 755) in this issue of AJPH. The authors use the National Health Interview Surveys to assess temporal trends of yoga, tai chi, and qigong use among US adults. They found a substantial increase in these modalities over the study period, with the principal reasons given for engaging in yoga, tai chi, and qigong being that participants perceive them as beneficial, holistic, and natural. The evidence base for salutary effect of any of these modalities is not robust; there is less attention paid to them than to more traditional medical interventions. And yet, it seems to us that behaviors that are gaining in traction substantially in the population specifically because they are perceived to be healthy are indeed worthy of investigation. We should better understand the effect of these approaches and how they can be incorporated into approaches that generate health to enable living more fully.

Third, recognizing health as a means and not an end allows us to consider the world around us, which shapes how we think, act, and behave and ultimately generates health in populations. Although we may be willing to accept a narrow, individualistic focus, a focus on the individual’s health as the measure of interest, it becomes much harder to maintain such a focus when we recognize that we are trying to generate health as a means of enabling other achievements. Hence, efforts such as those documented by Ferdinand et al. (p. 748), who show that states with a ban on texting while driving had, on average, a 4% drop in motor vehicle–related emergency department visits, demonstrate how creating a healthier context can lead to the production of health, creating freedom from morbidity and the opportunity for living a fuller life.

THE HEALTH ENGINE

At some level, recognizing health as a means not an end may seem self-evident; at another level it is a departure from a science and practice that aims to achieve health as its outcome. Seeing health as a means pushes us to a focus on the quality of our life, on asking questions about approaches that may enhance that quality, and on the world around us, considering its centrality in creating opportunities for living a fuller life. Shifting our thinking to health as a means and not an end stands, in our estimation, to be a useful realignment in our approach and has potential positive consequences for population health.