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What's in a word?
Defining health

care health soundness attention well-being oversight healthcare

Four definitions of health

The indirect object of care in healthcare is, of course, health, to which we now turn our attention. Compared to the noun/verb care, the noun health is neat and simple, care for the condition of an organism its grammar straightforward, its lineage clear, and its dictionary senses few (Table 3). This word is just as rich in meaning, however, intensifying and sharpening many of the insights into the human condition that we've already begun to unwrap in our analysis of care, especially the dichotomy between suffering and hope. In this chapter, we will examine the first dictionary definition of health, which essentially delineates the grammatical dependencies and requirements inherent in the word. The second dictionary definition (explored in the next chapter, Defining soundness) arises from the etymology of health, that is, wholeness (soundness). It is from this definition that the notions of disease and injury emerge, and from there a problem-oriented view of healthcare. The third definition is complementary to the second, furnishing a goal-oriented view of healthcare based on Defining well-being.

Table 3. Four Senses of the Word Health*
1The overall condition of an organism at a given time.
2Soundness, especially of body or mind; freedom from disease or abnormality.
3A condition of optimal well-being.
4A wish for someone's good health, often expressed as a toast.

Definition 1: Condition

health 1: The overall condition of an organism at a given time.

Of the four definitions of health, this one is the most abstract, the most neutral. Health, in this sense, is simply a condition, a statement of fact. The condition* of an organism refers to its mode or state of being. care for health mode* is the more active term (a way of doing or acting), state is the more static.

The familiar English word state has many uses and meanings, both technical and common, and the notion of state pervades our language through a family of related words (stand, stable, status, instant, distant, and others below). Although each of these words conveys a slightly different idea or meaning, they all inherit a common sense that ties them together. What these words have in common is the root [sta-] which means to stand or a way of standing. The idea of standing is closely tied to our everyday intuitions about space and time. Standing implies both being in a location and remaining in that location. The atemporal aspect of standing is conveyed by the words static, stationary and constant, while the spatial aspect is hinted at by the words stage, station and statue.

We know from experience that a given object stands in one and only one location in space at any given time. Of all the possible locations, an object is in one actual location. By close analogy to physical space, cointoss icon we intuitively understand that state space consists of several possible locations (modes or states). At any given time, however, an entity actually exists in only one of these possible states. To make this as intuitive possible, we might choose the coin toss to serve as an icon for this notion. All of us have tossed a coin to see whether it will land heads-up or tails-up because we know that it must end up on one side or the other and not both. For the coin toss, there are two possible outcomes, only one of which will become the actual outcome. Thus, the Notion of State centers around the dichotomy between actual and possible.

Another way of looking at the actual/possible dichotomy and the notion of state is through the concepts of statistics and probability. The word statistic belongs to the same family as stand and state, and the field of statistics deals with the descriptions of various states. Probability theory is a set of axioms and theorems that allows us to make inferences from such statistical descriptions. When we look toward the future, probability is stated in terms of likelihood, the number of states of (actual) interest related to the number of possible states. When the events in question have already occurred, we state the probability in terms of frequency, the number of times the states of interest are actually observed related to the number of observations (possible outcomes).

Condition as a mode of being conveys a more active sense than state, but mode, too, implies several possible alternative ways of doing or acting, only one of which is actualized at any given time. Furthermore, a condition (either mode or state) is static only at any given time. The condition (mode or state) typically does change over time.

Microstates and macrostates

A single coin toss has but two possible outcomes, but we might also imagine a combination of coin tosses, or the roll of several dice, or a hand of playing cards, in which the number of possible outcomes is quite large. The number of possible states for the roll of two dice, for example, is six times six or thirty-six. The number of different poker hands is about 2.6 million. We will call each possible outcome a microstate. Each microstate is equally likely, but typically certain groups of these microstates are more desirable (more wished for) than others. We may group the microstates into classes such as "full house" and "three of a kind" based on certain similarities and call these classes macrostates. The number of microstates that make up any given macrostate determines the likelihood of the macrostate. For example, the macrostate called a "straight flush" has forty microstates, the "four-of-a-kind" macrostate has 2,496 microstates, and the "three-of-a-kind" macrostate has 122,304 microstates. So a straight flush is more uncommon than four-of-a-kind, which is more uncommon than three-of-a-kind.

In the previous chapter, Defining care, I broached the topic of entropy from the perspective of irreversible energy transformations. In a statistical interpretation, the entropy S is proportional to the natural logarithm of a quantity W representing the number of microstates corresponding to the macrostate S.

S = k ln W,

in which k is the Boltzmann constant. The greater the number of microstates corresponding to a given macrostate, the greater the entropy. In other words, the most likely macrostate of a system is the one with the greatest entropy. In poker, of course, highly unlikely macrostates do occur from time to time, but in statistical mechanics, the number of microstates are such that one would have to wait interminably for even slight fluctuations of macrostates to occur spontaneously.

An indirect object of the indirect object

Returning now to the grammar of health , we have stated that health (as condition) is the indirect object of care, the object toward which care is directed. care for the condition of an organism But condition itself requires an indirect object (as a modifier), the object to which the condition (state or mode) applies. Care cannot be directed toward "the condition" in isolation, but rather must be directed toward the condition of something. Moreover, it is not the condition of just any object that will do.

When one talks about health in ordinary conversation, it is nearly always in reference to the health of a person, pet or favorite plant. Occasionally someone will talk about the health of a corporation or business, or something as nebulous as a political party, the national economy, or the ecology of an area. One does not ordinarily speak of the health of a rock or a nail or a bag of marbles, for example, and it would be unusual to say anything about the health of an inanimate machine no matter how complicated, except in jest. Health, then, refers to the condition of a complex, self-organizing, self-sustaining entity, in this case a living organism, a human being.

An organism is a complex, self-organizing, self-sustaining entity. In other words, a living organism is highly ordered and, therefore, improbable, so the second law of thermodynamics would seem to be violated. But organisms take in energy in the form of relatively low entropy molecules and discard the same atoms in the form of higher entropy molecules. Through metabolism, organisms participate in the dissipation of energy. Thus the overall entropy increases as required by the second law. Nevertheless, within the organism itself, macrostates that are compatible with sustained metabolism have comparatively few microstates, and therefore the entropy within the organism is low. When we refer to the health of an organism, we are above all referring to this low entropy state (structures) and the low entropy modes of action (functions) that preserve this state, all of which brings us to the second definition of health, soundness.


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