Introduction

This article has two goals. The first is to go beyond a mere account of the History of Medicine, despite its many interesting facets, and present a provocative scholarly discussion of definitions of medical health and illness by using a wider lens, both historically and conceptually. The second is to bring about a miracle in the reader. This study is designed to persuade and mobilize the reader, to widen the definition of personal health to include the health and well-being of the global human family and the human biosphere.

Health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity, according to the World Health Organization. However, in the face of power and wealth gaps, will not privileged elites define well-being by way of expecting underlings to accept the lack of health for the benefit of the elite? What if physical, mental, and social well-being antagonize each other? Many other questions may be asked.

Let us look at the second question. When you jump into the water to save the life of a drowning person, you are willing to sacrifice your health and life for your own mental and social well-being, being a noble, morally healthy member of the community. Conversely, if you do not jump, and the person drowns, your physical health may deteriorate due to your shame at having failed to be the moral person you thought you were. A bad conscience, said Nietzsche (1887), is a kind of illness.

I am sickened by the fact that I live in historic times with narrow and short-sighted definitions of health. I am a physician and psychologist by education and could lead a comfortable life somewhere in the “penthouse” of humankind’s global home. However, I can not. My mental health would be in jeopardy, and this would ultimately also bring down my physical health. I cannot close my eyes before our diseased global environment, or the millions of children around the world who die of easily preventable diseases before they have reached the age of five. When I look back at Hitler’s Germany, I wish that Germans had stood up and not by at the cruel demise of millions of people.

Therefore, today, I cannot idly stand by every year’s Holocaust-size mass-dying. My mental health depends on me standing up. It depends on me doing more than petty charity. John Stewart Mills in the nineteenth century spoke of ramshackle states, and Robert Jackson (1990) described quasistates. Currently, we live in a ramshackle global village. I cannot focus on my own narrow individual physical health in the face of global squalor. I therefore dedicate my life to restructuring the global system toward a decent global village. In the course of this life-design I am willing to pay the price of taking risks for my physical health so as to maintain my mental health and thus also the long-term basis for my physical health.

What is a decent global village? Avishai Margalit (1996) in The Decent Society, calls for institutions to no longer humiliate citizens – just societies no longer suffice; the goal should be decent societies that transcend humiliation. Decency reigns when dignity for all is made possible. Decency calls for a joint effort to attain the goals of the United Nations Millennium Declaration of September 2000. Decency calls for a new definition of medical health that includes everybody’s responsibility for building a decent world that is socially and ecologically sustainable and everybody can live a dignified life.

Why do we need such a wide definition of personal health? Because of global interdependence! Two recent catastrophes starkly illustrate this interdependence, one in the social and the other in the ecological realm. The fall of the Twin Towers on September 11, 2001, demonstrated that local self-interest, in this case American self-interest, cannot be protected by excluding the wider world from the equation of well-being. On the contrary, defining self-interest too narrowly has counterproductive effects. Global cultural-social-emotional climate changes are no trivial and negligible matter, they can have painfully factual effects, and this message was delivered on 9/11. Hurricane Katrina is the ecological equivalent of 9/11. Hurricane Katrina, on August 29, 2005, demonstrated that American self-interest cannot be protected by excluding global atmospheric climate changes from the equation. Global atmospheric climate change is as painfully factual as cultural-social-emotional climate change. As medical symptoms often point to more general systemic diseases, these two peak symptoms could be interpreted as pointing to deeper shortcomings in currently used calculations of self-interest and well-being.

The reach of morals is called the scope of justice. Peter T. Coleman in Deutsch & Coleman (2000) defines it as follows: “Individuals or groups within our moral boundaries are seen as deserving of the same fair, moral treatment as we deserve. Individuals or groups outside these boundaries are seen as undeserving of this same treatment” (p. 118). In the case of the ecological and social realms discussed above, the solution clearly is to widen the scope of self-interest and related responsibilities, and place this new scope, not merely on the shoulders of some politicians and diplomats, but at the core of every world citizen’s personal health definition. In today’s interdependent world every single individual is a player on the world stage and humankind’s health and survival depends on wider horizons for what we call health and how we define it for every world citizen.

I accept global responsibility to be my personal responsibility, and I do that not just theoretically, not just as a lofty ideal that is far removed from my day-to-day life, so I have redesigned my entire personal life. I explain my experience of making the leap towards a truly global identity as learning to swim and not to cling. “Swimming,” to me, means building global relationships of mutual support, or as Robert Axelrod (1990) calls it, reciprocal altruism. It means listening to Morton Deutsch (1973) and embedding his insight into my personal life as a global citizen that “cooperation breeds cooperation, while competition breeds competition.” Being able to connect flexibly and pro-actively, and insist untiringly on reciprocal cooperation, is at the core of my new global identity. Learning to “swim” entails a leap of courage, a momentum of trust that the water will carry. This leap is the miracle I would like to bring about in every human.

Therefore, terms such a “health,” “disease,” “illness,” or “medical” are treated here as historically evolving concepts whose definitions change over time. Therefore, no fixed definitions can be given at the outset.

However, I should briefly explain my personal definition of health. As already discussed, it is deeply related to human rights ideal of equal worthiness and dignity for every human being (and extensions beyond the human world). I believe that human rights represent a normative framework that is better adapted to an emerging global knowledge society. It is therefore that I wish to encourage every inhabitant of the globe to abandon “we/them” differentiations and define themselves as “we,” as “we humanity,” who, instead of pointing fingers at each other, together search for the best ways to provide our children with a future in a livable world.

This article has three parts that are drawn together into concluding remarks at the end. The first part sets out a brief overview of health, and approaches to health, during the first ninety percent of human history; part two addresses the past 10,000 years; and part three focuses upon the transition of which humankind is part at this time.

Historic Changes of Health and Illness and their Definition

The First Ninety Percent of Human History

Anthropologists explain that the first ninety percent of human history went by relatively peacefully, with small bands of about 200 to 250 hunter-gatherers cooperating within noticeably egalitarian societal structures. The available abundance of wild food provided hunter-gatherers with benign expandable resources and a win-win framework. William Ury (1999) explains this early state of human affairs comprehensively in his book Getting to Peace.

Certainly, food foraging life was not as serene or rosy as currently portrayed in many college cultural anthropology textbooks. Human nature entails no noble essence independent of culture – no savage essence either; human nature is always intrinsically cultural. However, archaeological findings show that the health and quality of life of early hunters and gatherers were high, superior to the health of most people in subsequent societal arrangements. Mark Nathan Cohen (1977) writes:

The earliest visible populations of prehistory … do surprisingly well if we compare them to the actual record of human history rather than to our romantic images of civilized progress. Civilization has not been as successful in guaranteeing human well-being as we like to believe, at least for most of our history (p. 131).

Cohen explains that prehistoric hunter-gatherers were better nourished than most subsequent populations, primitive or civilized. Remains of humans living in early prehistoric environments show that they often had large bodies with few signs of malnutrition. In subsequent historic times, human size and stature more decreased than increased, in most parts of the world, until the nineteenth or twentieth century.

Anthropologists obtain data on health, disease, and death from ancient populations using the methods of paleopathology, the study of ancient disease. Paleopathology gives glimpses into conditions in ancient populations. It also contributes to an evolutionary perspective of disease. By looking at populations in different environments over time, insights are gained into the long-term relationships of human biology, culture, and disease.

An example of the use of paleopathology is to document changing patterns of disease and health that took place during the transition from hunting and gathering to agriculture. Signs of infection seem to increase as settlements increase in size and permanence. Enamel hypoplasia, for example, suggests that nutritional stresses became more frequent and more severe as farming replaced foraging in different parts of the world.

Not only did early hunter-gatherers enjoy superior health over their agriculturalist successors, they also enjoyed the quality of life connected to comparable peace. There is no archaeological evidence for systematic war prior to 10,000 years ago, no proof of organized fighting among hunters and gatherers. Haas (1998) states that the Hobbesian view of humans in a constant state of “Warre” is simply not supported by the archaeological record. The available archaeological record allows for the educated hunch that organized killing indeed started later, and that human nature does not force humans unavoidably into destructive Hobbesian competition. On the contrary, older evolutionary roots seem to favour relationships and cooperation, the very cooperation that is needed in the interdependent world of the 21st century, the very reciprocal altruism that merits being included into today’s definitions of social well-being.

The Past 10,000 Years

Roughly 10,000 years ago, Homo Sapiens populated the globe, at least its easily accessible regions, and uninhabited land became scarce. People could no longer just wander off to the next virgin valley abundant with wild food; the neighboring valley was already populated by others (circumscription is the anthropological term). Increasingly, people had to stay put, become more sedentary, and make do with the land under their feet. Intensification is the anthropological term for the solution that emerged, namely the use of land as resource for livelihood, in other words agriculture.

Agriculture introduced a profoundly new way of life, much more malign than previous, because land is either mine or yours, a state-of-affairs that represents a win-lose logic, which, in turn, fuels war. International relations theory uses terms such as the security dilemma to describe how arms races and war were almost inevitable in this atmosphere of fear of attack from outside one’s community (Posen, 1993, and Hardin, 1995).

Hierarchical societies evolved in response to the new circumstances of agriculture and the security dilemma, with masters at the top and lesser beings at the bottom. Human worthiness became ranked, with different degrees of honor attached to each stratum. Examples of the so-called early civilizations are numerous, among them those in Mesopotamia, Egypt, or, later, the Roman Empire.

Time travelers from the 21st century would identify at least three areas in which, from their point of view, health was absent or compromised in human history. The first would relate to the question of “health for whom?” or to the fact that underlings were treated as commodity unworthy of the same attention as their masters. The second area would relate to the lack of insight into the biological, physiological, biochemical, endocrinological, neurological, and emotional underpinnings of health. The third area would concern the tendency, in hierarchical societies, to buy status and pay with health. All three are still relevant concerns and merit a closer look.

Health, for Whom?

Earlier, we asked who defines whose well-being, and what if the oppressor calls for underlings to obediently accept scarcity to secure the oppressor’s well-being? The very word civilization may have acquired its positive taste due to this very dynamic. What if human progress has been paid for with the health of lowly masses? Did the development of agriculture allow for leisure time and longer and healthier lives for the masses, or just for the elites? As discussed earlier, it seems that the adoption of agriculture brought mixed health results at best.

Martin Buber (1944) developed a philosophy of dialogue, in which he viewed human existence in two fundamentally different kinds of relationships I-It and I-Thou. An I-It relationship is the normal everyday relation towards things. Fellow human beings are often treated as Its, parts of the environment. This contrasts with I-Thou relationships, into which a person enters with her or his whole being and experiences genuine encounter and dialogue.

Hierarchical societies during the past 10,000 years treated underlings as Its, as commodity, unworthy of the same care as their masters. While hunter-gatherers subjugated nature by making tools, hierarchical societies subjugated animals (domestication), and people, and turned them into lesser beings, underlings, or slaves. There is abundant proof of this historic development. The pyramids of Gizeh are just one, very impressive, example of masters letting underlings toil for the master's elevation.

This state-of-affairs was seen as legitimate, as a sign of civilization. In his book Early Civilizations, Bruce Trigger (1993), reminds us that “because of the pervasiveness of inequality, no one who lived in the early civilizations questioned the normalcy of this condition. If egalitarianism was known, it was as a feature of some of the despised, barbarian societies that existed beyond the borders of the 'civilized' world” (p. 52). During long stretches of human history that inequality – the vertical ranking of human worth – was much more than a reluctantly tolerated evil; it was hailed as the very core of civilization. Equality was “barbaric.”

With respect to health, lowly people, underlings, slaves, were tools whose functioning was valued to a certain point, however, like any tool, when it is easily replaceable, it is thrown away. The health of underlings was thus inscribed in their utility as tools. Only the ruling elite was worthy of medical care for its own sake. Not only did underlings suffer due to being treated as tools, ranked honor societies also required masters to routinely subjugate underlings, in order to teach them to accept the pain of their lowliness as honorable medicine. In other words, not only was the health of underlings regarded as relatively unimportant, this negligence was compounded by the intentional hurtful oppression of underlings so as to force them to succumb to the definition of society as a ranked one.

Sometimes the pain of subjugation was even institutionalized. Women in China, for example, were reduced to the status of dependent and helpless toys through the traditional practice of foot binding. Basically, the gist of Chinese foot binding reigned wherever hierarchical societies prevailed. Underlings in coercive hierarchies were routinely forced into artificial incapacitation. Mutilation and incapacitation were seen as normal for underlings throughout the past 10,000 years. Health, as understood today, was beside the point.

Jiuquan Han (2007) describes the Five Penalties (wu xing) inflicted on criminals in historic China, and how destroying their health and lives in the cruelest way was seen as entirely appropriate:

In the Shang Dynasty… different means were utilized to kill a criminal by hai (mincing up into meat), fu (drying the criminal), fen (burning), pou xin (digging out the heart), ku (cutting open) and ti (scraping flesh off bones) … (p. 2).

Health, How?

A time traveler from the 21st century would report a lack of insight into the biological underpinnings of health and illness during humankind’s past. The time traveler would witness many alternative conceptual models of health and illness being applied, some with great success (indigenous medicines around the world entail remarkable insights), others with less success. Among the less appropriate approaches, three would be remarkable, first, the use of analogy to define health and illness, second, the dominance of afterlife-imagery over life before death, and third, medical models drawn from societal arrangements.

Analogy

Traditional Chinese medicine, Indian Aryurveda, or other indigenous medicines enjoy considerable standing in modern times. However, rarely will today’s cutting-edge medicine recommend hot iron cauterization for “counter-irritation,” meaning that pain or irritation was inflicted in one part of the body in order to relieve pain or inflammation in another area. In other words, the use of analogy (Gentner & Kurtz, 2006) often led to what today would be called inappropriate misperceptions.

After-life imagery and its potentially destructive power

Following the title of a four volume work edited by J. Harold Ellens (2004), The Destructive Power of Religion, Violence in Judaism, Christianity, and Islam, the Roman Catholic Inquisitions may serve as a stark example. Sentences on heretics varied from fines to execution by burning at the stake. Those who were condemned had to participate in the religious ceremony of auto de fe, from Latin actus fidei or act of faith, a ritual of public penance, after which they were “handed over” to secular justice which carried out the sentence.

António José Saraiva (2001) describes the Portuguese Inquisition, and how, in Lisbon, the condemned would be marched to the place of execution to be executed. The condemned persons were bound to posts surrounded by pyres of wood. They were asked if they wanted to die a Catholic or not. Those who said, “Yes,” were immediately garroted by the executioner from behind the stake. Their corpses were burnt later. Those who replied with, “No,” were taken to a higher post, where it was announced that they were abandoned to the devil who was nearby to receive their souls and carry them off to hell. Saraiva continues describing the scene:

Long poles with firebrands tied to the tip were “rented” to volunteer torturers who juggled with them until they touched the faces of the victims and carbonized them. Only after the crowd had enjoyed this sport to the hilt, did the executioner set fire to the pyre at the base of the stake. The Lisbon riverside is frequently windy and a breeze would often deflect the flames. The seated victim was perched at such a high altitude above the pyre that the flames would not reach beyond his feet or legs. The fire would then not choke him but grill him during an hour and a half or two hours until he expired. The victim’s screams, sometimes verbal: “Mercy for the love of God!” excited the crowd’s glee and would be mockingly imitated (pp. 110-111).

Clearly, in this case, health before death was surrendered to an imagery of well-being after death, well-being to be attained or forfeited. The ruling elites, the instigators of these practices, might have authentically believed in their religious explanations, or they might have used them as political ploys to stay in control, as argued by David Graizbord (2006). In any case, as Maureen Flynn (1991) analyzes, the spectacle and ceremony of the auto de fe, combined with the subsequent sentencing, succeeded in filling people with awe and fearful apprehension of their own final judgment. This fear overruled what could be called humanity, or compassion with fellow human beings, or concern with the victims’ health and well-being before death rather than after death.

Medical models drawn from societal arrangements

The insight that infants, in order to grow up healthily, need caretakers to extend loving physical and emotional closeness to them is being recognized only very recently in mainstream contemporary medicine and pedagogy. John Watson (1928) famously wrote, in his books Psychological Care of Infant and Child, that kissing your child goodnight equaled overindulgence. A brief bow and hand shake before turning off the light would be the correct way to love your child. In the same spirit, feeding a newborn on demand is a relatively recent medical advice given to mothers. Not long ago the newborn was to be treated like a machine, fed according to the clock, from a bottle and not the breast. Nestlé and Ross laboratories developed white powder and plastic nipples. Rima Apple (1987), describes what was called scientific motherhood. In general, living life according to biorhythms was seen as unscientific.

Following the success of Newtonian Physics, which gave rise to automation, factories, and industrialization, the paradigm of human health was fashioned according to the machine and made subservient to industrialization. This worked best when enforced by certain ethics, like the Protestant Ethics as described by Max Weber, and supported by older paradigms drawn from societal institutions such as the military. From Sparta’s ruthless efficiency to the Prussian military machine and its discipline, the military was a structural forerunner of the Newtonian machine.

In other words, the success of a machine made of smoothly working sub-parts, be it the military machine or, later, the industrial factory, was perceived as a model onto human health. The success of a disciplined military machine, followed by the success of the Newtonian machine, facilitated the rise of inappropriate and ultimately deeply unhealthy paradigms of human health. The machine paradigm caused intense harm where the mere acknowledgement that human beings are served better by conceptualizing themselves as living creatures would have prevented it. From the point of view of contemporary science, the workings of human bodies are closer to the realm of animals than to Newtonian machines and better modeled by an animal paradigm or living creature paradigm. Alice Miller (1983) comes to mind, and her argument that the inhumanity entailed in the childrearing practices of its time paved the way for the mayhem perpetrated by Nazi-Germany.

To summarize this section, human history is filled with approaches that could be called unhealthy. Our time travelers report cites the fallacy of misplaced analogy, the hurt from allowing afterlife-imagery to trump quality of life before death, and the mutilation stemming from medical models derived from automated machine systems. Such approaches filled the gaps that were left by the lack of insight into the biological underpinnings of health and illness, and they became aggravated upon the arrival of agriculture, when approaches born out of ignorance turned violent due to the security dilemma that facilitated oppressive hierarchical societies. Health, or Higher Status?

If we look again at China as an example, certain Confucian teachings are very useful still today. However, nobody would opt for preserving the Chinese foot binding that was already mentioned above, even though it lasted for a thousand years, during which about one billion women had their feet bound. Howard Levy (1992), to name but one author, describes the details. Chinese foot binding was a tradition of twisted deformed feet, pain and torture, that began late in the Tang Dynasty (618-906) until it was finally outlawed in the 1911 Revolution of Sun Yat-Sen. It began as a luxury among the rich and made women more dependant on others and less useful around the house. It soon became a prerequisite for marriage and was especially hard on the poor who could not afford servants.

Many traditional practices during the past 10,000 years resemble foot binding. Status was frequently bought at the expense of health. It was paid for by pain and suffering. The list is long, from foot binding to wasp waists and to modern high-healed shoes, from inappropriate architecture to dysfunctional design of environments and lives, merely to attain higher status. The rich usually are still able to mutilate themselves and live relatively well, due to servant’s assistance, however, lesser people usually pay a much more substantial price for their blind admiration and slavish copying of elite life style, real or imagined. In my book on humiliation (Lindner, 2006) I call this phenomenon the voluntary self-humiliation that underlings perpetrate on themselves, often without being aware of it (158-160).

To conclude this section on the past 10,000 years, time travelers from the 21st century would identify at least three areas in which, from their point of view, health was absent or compromised. All three areas are still relevant concerns today and therefore deserve our attention. A stark present-day example of voluntary self-humiliation is the person who aspires to a sun-tan so as to appear to be joining the higher ranks of the jet-set, only to pay with skin cancer, in a world that is inflicted with global warming as the price to pay for humankind’s lack of insight into the physical and chemical underpinnings of a healthy global climate.

The Current Transition

A few hundred years ago humankind began to face a second transition that is still in full swing and that is as deep as the one that occurred roughly 10,000 years ago. Ten thousand years ago, human beings, still comparably equal in worthiness, were subjugated by new masters, turned into tools, and forced into ranked societal institutions. Today, in the course of the currently unfolding second transition, the call gets ever louder to restore human worthiness to its former egality.

The current transition, in which we, the presently living generations of humankind take part, made itself first known to a wider audience through the dramatic emergence of ideas such as the French revolution’s motto of egalité, or the idea that everybody has a right to happiness as enshrined in the American Declaration of Independence. These ideas had earlier roots that date back to Italy’s Florence and the Renaissance. Rebellious founders of new religions and philosophies around the world have always resisted the notion that there should be higher and lesser beings worthy of more or less earthly well-being. One of the more recent arrivals on the stage of human culture would be the Sikh religion with its aversion to ranking human worthiness; Islam would be another, slightly earlier example; and Jesus’ message had a similar core; the list is long. In other words, the idea of equal dignity for everybody has always existed and always survived, everywhere on the globe. It is neither a new, nor an exclusively Western idea. However, usually during the past 10,000 years, indeed, until recently, such rebellious ideas were soon subjugated into hierarchical institutions, leaving the toiling masses but to yearn for equal dignity and well-being only after death. Perhaps the force that drives ideas of equal dignity to the surface of everyday affairs today, and onto the tables of the powerful and privileged, is provided by technological innovations that enable humans to relate to themselves, and to their home, planet Earth, in profoundly new ways.

People around the globe today communicate and meet as never before. As William Ury points out, they increasingly use knowledge, not land, as the resource for their livelihood. Ury suggests that Homo sapiens, by creating a global knowledge society, returns to the win-win frame of hunter-gatherers since knowledge, unlike land, is an expandable resource, and thereby regains the potential for relatively peaceful egalitarian societal structures for the global tribe of humankind.

Some of the predicted changes can already be seen with the rising awareness of human rights ideals helping to change the hierarchical order. With this advent, the ideal of equal dignity for everybody enters the stage and the notion of humiliation as violation of human rights and equal dignity becomes salient.

Since 1996, my research focuses on the phenomenon of humiliation. I conducted a four-year doctoral research project, entitled The Feeling of Being Humiliated: A Central Theme in Armed Conflicts. A Study of the Role of Humiliation in Somalia, and Rwanda/Burundi, Between the Warring Parties, and in Relation to Third Intervening Parties, from 1997 to 2001. In the final dissertation, submitted to the University of Oslo (Lindner, 2000) I used a diagnosis-prognosis-therapy methodology for identifying and healing humiliation. Since 2001, I work on building a theory of humiliation and a global and transdisciplinary field of humiliation studies (www.humiliationstudies.org).

A contemporary definition of humiliation can be based on the human rights ideal of equal dignity for all. The first paragraph of Article 1 of the Universal Declaration of Human Rights (UDHR), which was adopted by the United Nations General Assembly on December 10, 1948, reads: “All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.” In this context, humiliation is the enforced lowering of any person or group that damages their equality in dignity. To humiliate is to transgress the rightful expectations of every human being and of all humanity that basic human rights will be respected.

The word humiliation refers to three different elements of the experience: the perpetrator’s act, the victim’s feeling, and the social process. The current historic transition moves humiliation from being solely the privilege of the elite, the privilege to subjugate underlings and avenge humiliated honor among elites, to becoming a right of those at the bottom, the disadvantaged. In the new framework, the downtrodden underling no longer is expected to acquiesce quietly to the pain of subjugation, but gains the right to feel humiliated. The have-nots around the world, today, are increasingly socialized in new ways and allowed to feel humiliated by their lowliness, a lowliness that is now defined as illegitimately humiliating. Elites, on the other side, face the opposite call: they are called upon to regain humbleness and are not anymore given permission to resist this call by labeling it as humiliating. Elites who arrogate superiority lose their age-old right to cry, “Humiliation!” when asked to descend and become humble.

The human rights revolution could be described as an attempt to collapse the master-slave gradient of the past 10,000 years to a new level of equal dignity and humility. The practice of masters arrogating superiority and subjugating underlings is now regarded as illicit and obscene, and human rights advocates invite both, masters and underlings, to join in shared humility at the even level of equal dignity (see Figure 1).

It is important to note that the horizontal line in the middle of Figure 1 is meant to represent the line of equal dignity and humility. This line does not signify that all human beings are equal, or should be equal, or ever were or will be equal, or identical, or all the same. This horizontal line is to represent a worldview that resists the hierarchical ranking of human worth and value. Masters are invited to step down from arrogating their perceived higher worthiness, and underlings are encouraged to mentally and practically rise up from lowliness. Masters are humbled and underlings empowered.