Special Section Commentary

Choosing health David Ozonoff Department of Environmental Health, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA. E-mail: [email protected]


The Melkirch Model is an important effort to establish a common framework for sustainable programs to improve health. We briefly discuss the choice to focus health and the assumption that individual and population wellbeing are always compatible. Despite the inevitable difficulties in such an ambitious endeavor, the Model is part of a critical conversation. Journal of Public Health Policy (2014) 35, 407–410. doi:10.1057/jphp.2014.24; published online 19 June 2014 Keywords: Melkirch Model; health; Illth

If journals gave medals for bravery, the paper by Bircher and Kuruvilla1 would likely be in the running. Is bravery enough to succeed? Not often and not in this case. Does this mean the attempt was a failure? Again, no. Except for a few Brave Souls, surprisingly few have attempted the kind of urgent theoretical labor the authors have. Theory may not be the most urgent task when the waters are rising around us. The bailing, plugging holes, and rebuilding require (almost) All Hands On Deck. Almost. We still need to think about where the boat is heading and why we want to get there. It’s a task for only a few, and only a few have the ambition or temerity to try. But it still needs to be done and this article is a voice in a critical conversation. So that’s my first point: the Melkirch Model is an important move, even if, in my view it doesn’t succeed. Not succeeding is not failure, nor is it surprising. Pulling a loose thread in any definition of Health almost always threatens to unravel the whole thing. So the job of a critic is easy. Criticizing constructively isn’t. In the brief space here, as my contribution to the conversation, I will only try to identify some critical (unforced) choices the authors have made. Choices are often undeclared and often unconscious, but most choices involve trade-offs. Focusing on choices is meant to provoke discussion about alternative perspectives.

© 2014 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 35, 3, 407–410 www.palgrave-journals.com/jphp/


A Model, not a Definition Despite using the venerable WHO definition as a reference point, the authors only define health obliquely, choosing instead to represent health in terms of a model, the Melkirch Model. Definitions are about the Nature or essence of something. Models are about replicas. The authors’ usage of model is similar to a biologist’s when he or she talks about a mouse model. Mice are not people but they are close enough biologically to have all the complexity of a human while affording the possibility of investigating them in ways impermissible for humans. Moreover by standardizing on rodents, like a mouse or a rat, biologists have established a ‘stable target for explanation’. The Melkirch Model has both of these qualities: it is sufficiently complex to be realistic and it is meant to be a stable framework to allow collaboration among parties. That’s a deliberate choice – chosen because of the authors’ concern about collaboration among caregivers who must function as a team with their patients, and collaboration across sectors and among nations and the United Nations. But that makes it different from a general attempt to define the nature of health, the context within which they placed their effort. Moreover there are different kinds of models. This is not a model in the way a mathematician or physicist might use the word, a set of rules that exhibits the logical skeleton of the system we wish to explain or whose behavior we wish to predict. This is quite a different kind of model, but the authors seem to confuse what they are doing with a more formal or mathematical style when they talk about health as an emergent feature of a complex adaptive system. Complex adaptive systems are a recognized way to represent (model) the real world, but they have specified local rules, even if they exhibit emergent behavior on a global scale. Saying health emerges from a complex system is hand waving. It only has meaning when referring to a particular system stipulated sufficiently to allow one to make confirmable assertions. It has no meaning in this article beyond the idea that there is a ‘system’, that it is complex, and that it ‘adapts’ (to what internal essence or goal we don’t know).

Focusing on Health Let me briefly sketch another choice the authors could have made. They have chosen to focus on health. This hardly sounds like a choice, given the topic, but let me suggest that the perspective could have been


© 2014 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 35, 3, 407–410

Choosing health

different. Health’s sibling, wealth, is the sum total of Good Things in a society, but medicine and public health are traditionally occupied with the consequences of wealth’s complement, illth. Illth is a little used word coined by the nineteenth century English reformer and art critic, John Ruskin. Illth is the sum total of Bad Things in a society. I know, we in public health frequently complain that there is too much emphasis on disease and not enough on health, but focusing on illth is not the same as the conventional medical choice of focusing on disease. Illth widens the notion of bad things to encompass income inequality, shortsighted but unsustainable tactics, various ‘tribalisms’ (nationalism, religious bigotry, sexism, racism, and literal tribalism, among other things). Illth, like health, is a normative concept and depends on context, but the effect of context is clearer. At some stages in the development of a society nationalism might decrease illth, a lever to break the grip of a colonial power, just as capitalism might be a way to advance beyond social and property relationships holding back a society’s productive power. But at other times, we see the destructive power of capitalism and nationalism and its tribalist cousins, racism, religious bigotry, and all the other ‘isms’ that plague our modern world. The way historical and societal context influences our normative notions of illth are clearer than for health and that makes them easier to understand and deal with. The authors don’t defend their choice of making health their primary focus because it has become a ‘given’ that it should be our focus. I raise this to the level of ‘choice’ to provoke conversation and maybe even a rethinking.

The Individual and the Collective Another choice is to assume individual health and population health are similar and mostly compatible. But maximizing each person’s potential may be bad for population health (unless you are of the persuasion of philosophers like Ayn Rand who rejected ethical altruism for a radical egoism). Consider the rat population. Rats are one of the most resilient and adaptable creatures on earth but individual rats have high morbidity and mortality. The rat population is extremely healthy as measured by adaptability and resilience. Individual rats are not. On the other hand, some modern European countries have excellent health indices (a reflection of individual health) but they are shrinking because birth rates aren’t replacing population loss. Is the population

© 2014 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 35, 3, 407–410



healthy? It isn’t adapting and at current rates will disappear or be submerged in other populations. The Melkirch Model conjures these matters away by referring to “a healthy social context” without telling us how to recognize one. Can everyone be healthy but the population unhealthy? Opaque phrases like ‘healthy social context’ and ‘social engagement’ abound in the paper. Once we raise the hood on any of them, however, we do not see a tidy engine running things. Instead, there is a welter of connections and cross-connections that have bedeviled philosophers for millennia. I am not raising a question of jargon here (although there is quite a lot in this article, for example, ‘transformative, people-centered agenda’). This is a matter of meaning. In our everyday lives we can (perhaps) afford to ignore the conceptual depths. But one of the burdens of writing a paper about Big Ideas is that you cannot afford to ignore them once you raise them (and sometimes even if you don’t). The authors are experienced practitioners and deeply reflective, but they are like the biologist whose requirements for a ‘mouse model’ are that it is as rich and complicated as the human biology it substitutes for. They might also have opted for a stripped-down model, a skeleton of spare concepts, but they choose another path. Complexity characterizes their experience and they want a model as rich and complex as that experience. That was a choice. And while I am not persuaded it was the right one, we’re talking about it. In itself, that’s an accomplishment.

About the Author David Ozonoff, MD, MPH is Professor of Environmental Health at Boston University School of Public Health. He is an environmental epidemiologist who has worked with WHO and many local communities on problems of chemical contamination. He is Program Director of the Boston University Superfund Research Center.

References 1. Bircher and Kuruvilla (2014) Defining health by addressing individual, social, and environmental determinants: New opportunities for health care and public health. Journal of Public Health Policy. doi:10.1057/jphp.2014.19 published online 19 June 2014.


© 2014 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 35, 3, 407–410

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Choosing health.

The Melkirch Model is an important effort to establish a common framework for sustainable programs to improve health. We briefly discuss the choice to...
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