Vol.3, No.6, 378-382 (2011)
opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Health care needs need to be focused on health
Johannes Bircher1, Karl-Heinz Wehkamp2
1Hepatology, Department of Clinical Research, University of Bern, Bern, Switzerland; jbi@swissonline.ch
2Life Sciences Faculty, HAW Hamburg, Campus Bergedorf, Lohbrügger Kirchstr, Hamburg, Germany; karl.wehkamp@t-online.de
Received 15 April 2011; revised 10 May 2011; accepted 23 May 2011.
In the past decades health care and medicine in
most countries got more or less in a state of
crisis. This is not surprising because, so far,
there is no consensus about the nature of
health. This shortcoming inhibits constructive,
interdisciplinary dialogues about health values.
It renders priority setting controversial and
subject to power struggles. A new definition of
health, known as the Meikirch Model, could
correct this deficiency. It states: “Health is a
dynamic state of wellbeing characterized by a
physical, mental and social potential, which
satisfies the demands of a life commensurate
with age, culture, and personal responsibility. If
the potential is insufficient to satisfy these de-
mands the state is disease.” The potential is
composed of a biologically g iven and a person-
ally acquired component. Thus this definition
characterizes health with six essential features,
which are suitable for an analysis of and priority
setting in medical consultations and in health
care policy decisions. A wide discussion about
this definition of health followed by its imple-
mentation is expected to render health care in-
dividually and socially more beneficial.
Keywords: Health; Definition of Health; Health
Care Systems; Health Care Need s ; Meikirch Model
In most countries health care systems are now in a
chronic state of crisis. This is due to many reasons, yet a
rapid increase in costs and a change in values appear to
be predominant. Physicians have lost control of health
care in favor of economists and politicians. As a result
leadership is no longer based on medical but on eco-
nomic and political values. In health personnel this has
created much insecurity and frustration.
Currently, the predo minant question is how to redirect
the self-organization of health care systems and how to
integrate them into the resp ective societies. Management
of complexity is a challenge that is well known in large
organizations. Experienced leaders generally focus with
great care on the “product” their organization has to re-
alize. They insist that all persons within their realm of
influence know exactly what the purpose of their or-
ganization is. Yet, when it comes to health care, it is as-
tonishing that the very purpose of the system, i.e.
“health” cannot be described. Everybody speaks with
respect about health, yet no one can explain what it
really is. As a result, in most health care systems, the
level of misunderstanding and conflict is high. This can
be exemplified by the following statement: “Patients are
customers and physicians service providers.” This obvi-
ously is the opinion of economists, yet most physicians
and patients would wholeheartedly disagree. Many such
misunderstandings may be found at all levels of health
care systems. In order to guard against them, a new un-
derstanding about the terms of health and disease must
be created.
In 1946 WHO declared its famous definition of health
[1]. It reads as follows: “Health is a state of complete
physical, mental and social well-being and not merely
the absence of disease or infirmity.” At that time this was
a significant advance because for the first time it offi-
cially postulated the importance of mental and social
factors for health. Since then, however, our understand-
ing of physical condition s, mental functioning and social
wellbeing has markedly evolved. As a result the WHO
definition is now considered to be idealistic to an extent
that almost no one can consider him or herself to be
healthy. Consequently, agreement with this definition
has become limited and, at the present time, it can no
longer serve as a central concept for the implementation
of health care systems. We now need a concept of health
that respects the dignity of each person, distinguishes
between health and disease, provides essential elements
for the process of diagnosis and reimbursement and
clarifies the relationship between individual, and society.
An analysis of different descriptions of health reveals
J. Bircher et al. / Health 3 (2011) 378-382
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
that most of them have merits and validity from certain
points of view and limitations from others [2]. This may
be explained by the fact that it is difficult to develop
concepts with sufficient interdisciplinary merits. Most
authors know their own fields best and attach less im-
portance to others. The definition, which has become
known as the Meikirch Model, is based on experiences
reflected by physicians [3]. It uses six specific criteria to
describe health, all of which may be surveyed or inves-
tigated when examining human beings or health care.
Consequently, the Meikirch Model appears to be suitable
for application in medicine and in health care systems.
MODEL [4,5]
Health is defined as follows: “Health is a dynamic
state of wellbeing characterized by a physical, mental
and social potential, which satisfies the demands of a life
commensurate with age, culture, and personal responsi-
bility. If the potential is insufficient to satisfy these de-
mands the state is disease.” The latter includes sickness,
illness, ill health, and malady.
In this definition the potential consists of two compo-
nents, a biologically given and a personally acquired
potential (Figure 1). At birth the biologically given po-
tential has a finite value. Thereafter it decreases
throughout life and at the time of d eath it is zero. In con-
trast, the personally acquired potential is quite small at
the time of birth, but increases rapidly during childhood
and adolescence. It may rise throughout life, provided an
individual cultivates it. It may be damaged by neglect,
alcohol or dugs, etc. It may also be hurt by social sur-
roundings that are not supportive enough, over demand-
ing, or frankly destructive. Therefore social support for
health is crucial [6].
The demands of life are those that we have to respond
to in order to lead a healthy life. (They must not be con-
fused with demands a person may have toward life.
These have nothing to do with the Meikirch Model.) A
baby and a child are cared for by their social surround-
ings, such as mother, father, siblings, teachers, etc. Dur-
ing their productive years all individuals have to con-
tribute to the society. Pensioned elderly persons are
again supported by the society. Consequently, the de-
mands of life vary continuously with th e age of a p erson.
At the same time the culture of a society modifies these
demands, a factor which needs to be taken into consid-
eration. A final important aspect is personal responsibil-
ity of each individual for his own health.
In each person the decision about health or disease
depends on the balance between the total potential and
the demands of life (Figure 2). If the two partial poten-
tials combined outweigh the demands of life, a person is
healthy. In co ntrast, if they weigh less, the person is dis-
Within this context it is important to appreciate the
nature of these potentials and why they are essential. At
the time of birth the biologically given potential is the
result of the genetic equipment and of the quality of the
pregnancy. It consists of all biological aspects of life,
which need to be protected, properly cared for and
treated responsibly throughout life. The personally ac-
quired potential is more difficult to understand. It com-
prises not only every capability a p erson has learned, but
also some physical aspects that are acquired while
learning. The capability of forming immune reactions,
e.g., is biologically given, but the immunities we have
are acquired. Obviously, emotional maturity and spiritual
growth are part of the personally acquired potential. Fi-
nally, the way we overcome misadventures, injuries, and
possibly severe harm may support or damage our per-
sonally acquired potential.
A good example to illustrate the contribution of each
potential to the health of an individual is paraplegia re-
sulting from an accident to the spinal cord. Such a con-
dition (until now) represents an irreversible damage to
Tim e
gi ve n
Figure 1. The potential of a person consists of two
components, a biologically given and a personally ac-
quired potential. In the graph the two lines are drawn ar-
bitrarily, yet they show that during a lifetime the contri-
bution of each component to the total potential varies
Healt h
of life
of life
Combine d
Figure 2. The decision about health or disease depends
on the balance between the sum of the combined poten-
tials and the demands of life. As with the decision about
day and night the distinction between health and disease
is clear in a majority of cases, but in some instances it
may be blurred.
J. Bircher et al. / Health 3 (2011) 378-382
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
the biologically given potential. Yet, through rehabilita-
tion, which is exclusively concerned with the personally
acquired potential, such persons may again become in-
dependent and even professionally active. It shows that
the personally acquired potential may in p art compensate
for reductions in biologically given potential. This fact
creates hope and supports patients with chronic diseases
because they realize that they can do something about
their condition, even when improvement of their physi-
cal state can no longer be expected. In a similar way the
personally acquired potential gives hope to the elderly.
In order to fully appreciate the Meikirch Model, some
further detai l s need to be u nde rst o od:
1) A relatively large number of healthy persons com-
plain about discomfort and pains [7]. Consequently,
health does not imply a “state of complete physical,
mental and social well-being”, because most healthy
persons regularly hav e some co mplain ts. Yet, they know
how to deal with them. This observation further supports
the idea that health is related to an ability to master the
demands of life.
2) Chronically ill persons or humans with e.g. a
metabolic or an immunological shortcoming may need
long term treatment in order to lead a “healthy” life. For
this reason two states of health must be distinguished,
one without treatment and the other with a long term
therapy, such as in hypothyroidism, diabetes mellitus,
arterial hypertension, rheumatoid arthritis, etc.
3) The term potential may be somewhat elusive to
grasp because it has to do with the future of a person. It
must, however, be realized that medicine and health care
are not so much concerned with the present but with an
improvement of each person's future. The very purpose
of medicine and public health is to preserve or restore
whenever possible the immediate, medium, and long
term future of patients and citizens. For these reasons the
concept of “potential” is more appropriate than e.g.
“In any field, improving performance and account-
ability depends on having a shared goal that unites the
interests of all stakeholders. In health care, however,
stakeholders have myriad, often conflicting goals in-
cluding access to services, profitability, high quality, cost
containment, safety, convenience, patient-centeredness,
and satisfaction. Lack of clarity about goals has led to
divergent approaches, gaming of the system and slow
progress in performance improvement.” With this intro-
duction Michael Porter pleads for his concept of values,
which he defines as health outcomes achieved per dollar
spent (Figure 3) [8]. The problem of divergent objec-
tives is well known in business organizations. In fact,
experienced leaders take great care to identify and ex-
plain the purpose of their institution. By communicating
it they intend to reach a higher level of cooperation and
performance. In health care the overriding goal is obvi-
ous. All persons must work for the health of the people.
Therefore it is now of critical importance to urgently
achieve a consensus about what health is and to commu-
nicate it. It is our understanding that at present the
Meikirch Model is the best available response to this
Another independent method to appreciate the impor-
tance of a definition of health may be derived from the
social systems theory [9]. Ta bl e 1 shows some essential
Nursi ng
Physi cians
Relative s
Mi nistry o f Hea lth
Spe cialists
Fri ends
Figure 3. Lack of a common goal divides stakeholders
in the health care system: As many goals are pursued as
there are persons involved. Presumably this is a central
reason for the different crises and the slow progress of
health care systems.
Table 1. Comparison of some essential features of
medicine and health care with selected examples of
other social systems. Each system responds to demands
by speci fic actions. Whe ther or not an act ion takes place
is governed by the generalized symbolic medium of
communication. In the case of medicine and health care
this medium has no specific meaning, because health
and disease have, up till now, remained undefined.
Therefore, actions within this system occur much more
arbitrarily than in the other social systems. This is dam-
System DemandsGeneralized
symbolic medium
of communication
Economy Goods,
Services Money
($, £, €, CHF) Purchase or
no Purchase
System Justice System
of laws Agreement,
Court Order
Science New
Knowledge Peer
Review Financing,
Health CareImproved
Health Health and Disease
(undefined so far) Diagnosis,
J. Bircher et al. / Health 3 (2011) 378-382
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
features of a system. Each of them responds to demands
that induce actions. Whether or not this action occurs is
governed in each specific case by a generalized symbolic
medium of communication. For instance, in an economy,
people demand goods and services. Whether these are
purchased or not depends on money. Only if the price is
adequate for the goods or services, are they bought. In
the legal system there may be a demand for justice,
which can be responded to by an agreement or by a court
order. Both cases must conform to the law in order to be
valid. Therefore, in the legal system, the laws play the
role of the generalized symbolic medium of communica-
tion. In science there is a demand for new knowledge.
For both, the financing of projects and for their publica-
tion in scientific journals peer review is required. These
examples may illustrate two features of a generalized
symbolic medium of communication: It plays a central
role for the processes that occur within the system and
its nature is specific for each system. In medicine and
health care by necessity the concept of health and dis-
ease serves as symbolic medium of communication.
Consequently, it is pivotal for the health care system not
to leave health and disease within the realm of arbitrary
individual judgments, but to define them in such a way
that everyone can agree about them. If in health care
money would serve as generalized symbolic medium of
communication, medicine would become part of the
economy and lose its specific nature.
When opting for a definition of health, it is important
to compare it with the best possible alternatives. For lack
of space only two eminent examples are discussed here:
1) Christopher Boorse [10] proposed a biostatistical
value-free definition. He explains “health as the absence
of disease” and “disease as a type of internal state, which
is either an impairment of normal functional ability, i.e. a
reduction of one or more functional abilities below typi-
cal efficiency, or a limitation of functional ability caused
by environmental agents”. Normal functional ability is
defined by statistical comparison with an age and sex
specific reference group. The value of this definition of
health and disease consists in the fact that it is based on
measurements and statistics. It has been criticized, how-
ever, on the basis that the selection of a reference group
is not truly value-free, but requires a normative judg-
ment. In addition the definition does not structure the
health problem of p atients. If a statistical significance of
p < 0.05 is chosen, 5% of normal subjects are diseased.
In addition, to define health, it is needed to measure the
appropriate parameter. In practice this is difficult.
2) Lennart Nordenfelt [11] proposes a welfare theory
of health. He considers health to be the primary concept
in the web of medical thinking. He states: “A is com-
pletely healthy if, and on ly if, A is in a bodily and mental
state which is such that A has an ability to realize all his
or her vital goals, given accepted circumstances.” This
ingenious definition is normative and derived from the
action theory. For the purpose of medicine and health
care, though, the terms he uses are difficult to apply in
practice. How do we assess e.g. vital goals or accepted
3) Several other normative definitions use among
other criteria the need or lack of need for medical care as
a decisive factor to define health or disease. This leads to
circular reasoning because disease in turn justifies by
itself the administration of medical care.
The Meikirch Model is also normative. Its practical
importance lies in the fact that all six criteria for the de-
scription of health or disease may be assessed in consul-
tations with patients. Therefore they may serve as crite-
ria to analyze value in health care, i.e. health outcome
per dollar spent [12]. In addition, it structures the com-
ponents of health in such a way, that they may be used in
research, in advising individual patients, in medico legal
expertises and in policy decisions for public health. The
Meikirch Model may also serve to explain the nature of
medicine to members of other social systems, e.g.
economists, managers, politicians, lawyers, and scien-
tists. If they understand the model, it may provide the
common denominator for joint policy decisions [13].
This is particularly pertinent, because health care con-
tinuously evolves together with the other social systems.
If, as postulated by Porter [12], the measurement of
value must be its fundamental goal an d improving value
the driving force for every participant, the Meikirch
Model could become a pivotal reference point for this
As a next step the different stakeholders need to be
able to perceive the usefulness of the Meikirch Model
and to agree to apply it for interdisciplinary communica-
tion about health care. For this purpose it probably is
useful to start with a widespread discussion on this sub-
ject. More details may be found on a website [5]. Once
the Meikirch Model corresponds to a general under-
standing, it is expected that medicine and health care
will tangibly be more beneficial socially.
There are no funds involved from any side. For both authors there
are no conflicts of interest.
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