Physical Autonomy
Unnecessary Disclaimer: The biggest impediment to my writing is my perfectionism, particularly my desire to avoid publishing anything which doesn't include all the possible implications, questions, and domains which would be suggested by a given idea. This is obviously ridiculous, because it would mean never publishing anything – or at least, nothing less than a book. In an effort to actually write more, I'm forcing myself to avoid falling into that trap, but I feel the need to clarify that this post (and basically everything on this blog) are a sketch of thoughts about a particular idea I'm grappling with, and not meant as a complete representation of my thoughts on the matter.
Although it is probably possible to achieve "better health" in the absence of a clear and actionable definition thereof, it is very likely to be a less efficient and efficacious process than it would be with such a definition in hand. A full exposition of the commonly accepted definition of health, the problems with that definition, and possible options for reconciliation and redefinition, goes beyond the scope of this blog post, and perhaps of this blog entirely (no promises, though.) For some great work on that subject, I recommend Georges Canguilhem's important book "The Normal And The Pathological." But for my thoughts on one aspect of a clear and actionable definition of health, just keep reading.
The concepts "health" and "fitness" are typically treated as related but distinct, with the implication being that one's level of fitness can contribute to or detract from their health, but cannot define health in and of itself. I have no disagreements with this approach. However, those aspects of fitness which are usually included in a measure of a person's health are those which can be measured with the standard tools of physiology: things like muscle mass, resting heart rate, oxygen uptake, etc, and even more distantly, things like triglycerides, blood pressure, and body fat percentage.
It is not my intent to question the usefulness of such metrics as part of the measuring and connecting of fitness with health. When research is well conducted, we can draw reasonable conclusions about the relationships between fitness-related physiological measures and health outcomes. However, these metrics leave us unable to account for the impact of the lack of some characteristics of physical fitness on one's quality of life – characteristics and impacts which, I contend, can and should be considered part of our definition of health.
Greg Glassman, the founder of CrossFit, used (some version of ) the following example to illustrate the gap in the commonly accepted definition of health:
Imagine two men, both 80 years of age. Let's call them Bob and Joe. Bob has a perfect health panel – no notable diseases, not overweight or underweight, normal blood pressure, normal triglycerides, no heart problems. However, he is confined to a wheelchair, and lives in a nursing home for assistance, since he cannot get around effectively on his own. Joe is physically active. He walks to the store and carries his own groceries home, up the stairs to his third floor apartment, and exercises at the gym three days per week. But Joe has been diagnosed with cancer.
Who is healthier: Bob or Joe?
This thought experiment brings to light an important aspect of health which often goes ignored, and which is what I want to explore here. I will call this concept physical autonomy.
Defined briefly, physical autonomy is an individual's ability to navigate the physical world without relying on assistance. This autonomy exists is not something that an individual either has or does not have, but rather it exists on a spectrum, e.g. Bob has less physical autonomy than Joe, but perhaps he has more than Mike, who is paralyzed from the neck down. And Joe, though considerably more physically autonomous than Bob or Mike, may be much less physically autonomous than Alex, who is a twenty-five year old athlete in his physical prime.
Most of us implicitly include physical autonomy in the way we define health. That's why the question of Bob and Joe is tough to answer: the way that we actually interact with the physical world seems obviously important to us, but there is little room for it in the way the western world generally conceptualizes health. As a result, the bridge between fitness and health is built only on physiological metrics, rather than on a combination of those metrics alongside some set of physical abilities. It may even seem incongruous to ask a question like "how many pullups can you do?" or "can you run a mile without stopping?" in assessing someone's health. These questions are relegated to the related, but distinct domain of fitness.
This all points to a larger problem with the commonly accepted definition of health referred to throughout this article. Consider Bob and Joe: convention would suggest that Joe is the less healthy of the pair, but for most people, that isn't a particularly satisfying conclusion. Why is that?
I contend that it is because, if health is measured primarily or exclusively as a collection of physiological metrics being within a certain range, it is theoretically possible to determine a person's physical health with no regard for their experience of the physical world. Over time, this model – I'll refer to it as the physiological model of health – has become so entrenched that physiological metrics have become the sole standard for determining a person's status as healthy or unhealthy. It seems to be unimportant that in most cases, an upsetting of these physiological standards is discovered as a result of the patient reporting a change in their interaction with the physical world – they are unhealthy because the levels are off, not because their experience of the physical world has changed for the worse.
Within the practice of medicine, those professionals who choose to pursue fields such as physical therapy are often viewed as somehow second class – a medical student once told me that physical therapists weren't "real" doctors because they cannot prescribe medication. Fitness professionals are rarely even regarded in the conversation about health – it's standard practice to check with your doctor before beginning a fitness regimen, the implication being that medical doctors are the best equipped to judge the safety and effectiveness of an exercise or nutrition program. Often, this is blamed on the apparent litigiousness of western society, especially in the U.S., but I think it runs deeper than that. It is reflective of a strand in medical culture which naturally derives from the physiological model of health: if health is a set of physiological metrics, then the "real" doctors are the ones who can correct those metrics, often via pharmaceutical intervention.
I want it to be clear that I have no issue whatsoever with the use of pharmaceutical drugs when appropriate to treat patients, nor do I have an issue with the use of physiological metrics as part of the assessment of a person's health. But I do believe than the over reliance on this model is a large part of what is keeping Americans and westerners in general from being able to deal more permanently with their health problems. A reconceptualization of health may be the first step in effectively bridging the gap between the physiological model of health and the lived experience of the individuals actually dealing with personal health.
Note: I'd be remiss here if I didn't note that there are medical professionals working hard to implement a more holistic definition of health into their practice, implicitly or explicitly. For a couple of great examples, check out Barbell Medicine and the Docs Who Lift.