Spirituality in the Definition of Health
The World Health Organization's
Point of View

M.H. Khayat

The World Health Organization celebrated last year its Fiftieth Anniversary. On this occasion, you may recall that fifty years ago, "health" was generally defined in negative terms as "the absence of disease", just as you might define life as the absence of death. When the founding fathers of WHO came to prepare the Constitution in 1946, they concentrated First of all on formulating a definition of "health" that uses positive terms. It reads as follows in the preamble of the Constitution: "Health is a state of complete physical, mental and social well-being and not merely the absence of the disease or infirmity"[1].

This now well-known definition highlights the inadequacy of the old ideas of defining health in negative terms, and identifies three dimensions of health, the physical, the mental and the social.

This was a very important step forward. Indeed, I would say it was a cardinal milestone in the development of our understanding of health. Moreover, as a definition it has actually helped to shape our perception of what it is we mean when we talk about health as a concept.

However, it seems that there was a general feeling from the very beginning, that a fourth dimension was missing from this definition. There has been a growing awareness of what Arnold Toynbee referred to as a "spiritual vacuum" in many parts of the world, especially in the industrialized countries in the West. A vacuum that led to widespread psychological insecurity" with the consequent deleterious effects on mental and physical -health.

This question of "psychological insecurity" that plagues modern man has been the subject of considerable concern and discussion in WHO fora. To give just one example from a World Health Assembly, in 1983, Dr F. Mellbye, a Norwegian delegate, deplored signs, in his country at least, of a deterioration in mental health, manifested in problems such as alcoholism, drug abuse, criminality, social maladjustment and general unhappiness and fear of the future, at a time when the economic and social situation of his country was quite promising. What was lacking, he claimed, was not political or administrative understanding of the gravity of such problems, but basic knowledge within the behavioural sciences, and scientific measures and means of understanding the human character. Dr Mellbye called at that time for an expansion of research into the behavioural determinants of health [2].

These "behavioural determinants" have been expressed similarly but in other terms by Dr Abdul Rahman Al Awadi of Kuwait as follows [3]:

"Material progress in the present world has reached levels unprecedented in past history or civilization. Yet we find that what prevails in this world are anxiety and apprehension, so much so that one could say that the distinguishing feature of this age is a sense of loss and uncertainty. We have stripped man, over the last decades, of his spiritual values, and materialism is now in full control of all aspects of our life to the extent that man feels lost and restless, desperately seeking tranquility and peace of mind". 1 am quite certain" he concluded "that regardless of what we do to provide health care for the body and the mind, man shall remain lost and restless until we provide for the spiritual aspect of life".

These and similar views culminated in May 1983, at the Thirty-sixth World Health Assembly, in discussion of the issue [4]. At that Assembly, the question of the "spiritual dimension" was raised and discussed at some length. Viewed from a historical perspective, this was a momentous event in that such a discussion could even have taken place. In fact, it was the first international opportunity to clarify a vital issue that had always appeared to be beyond fruitful public debate.

The initiative came in the form of a draft resolution from twenty-two countries from different regions and with different religious beliefs [5].

The draft resolution was written in very simple and clear terms. It recalled the definition of health in the preamble of the Constitution. It then affirmed that the 44 spiritual dimension is implicit in such a concept of health". Recognizing "the major importance of the spiritual dimension in providing health care to peoples", it requested the Director-General "to take the spiritual dimension into consideration in the preparation and development of primary health care programmes".

From the beginning of the, discussion, Dr Al Saif from Kuwait [6] explained that the draft resolution rested on the premise that "all people suffer from worry and anxiety caused by the times in which we live". "Materialism", he added, dominated daily life to such an extent that spiritual values no longer count, and people are afraid of the future. The malaise could be ascribed to a large extent to a lack of respect for spiritual values and the denial of the spiritual dimension, which could help people to live with confidence in the future". He concluded that "whatever technological progress may be made, there can be no true progress so long as a person's body alone is treated; in short, both the body and the soul must be treated".

Dr M.N. Savel'ev from the then USSR became the "interpreter" of the position of countries in which the Church is separated from the State [7]. Although unable to subscribe to the draft resolution as formulated, he saw no obstacle to "recognizing the importance of the spiritual dimension in providing health care to peoples in some Member States". He clearly explained that although "the Director-General would find it difficult to take religious aspects into account in elaborating and developing primary health care programmes, ...that could be successfully undertaken by the Member States concerned in planning their national health care programmes". This seemed to be the general feeling throughout the discussions; and Dr Abdulla from the United Arab -Emirates, a cosponsor of the resolution, emphasized that his country never intended to compel "anyone to take the spiritual dimension into account, but left everyone free to do so or not, as they wished" [8].

The next step in the process was the preparation by the Director-General at that time, Dr Halfdan Mahler, of a brief statement entitled, "Global Strategy for Health for All by the Year 2000: The Spiritual Dimension", which may well turn out to be of historical value. It attempts to set forth the idea that any human being, regardless of religious creed, origin, culture or mental acuity, can reach agreement on what is meant by a spiritual dimension" and what implications it can have for health care.

Dr H. Mahler said [9] he had looked at the definition of "spirit" in the Oxford English Dictionary, and the first definition given was the "intelligent or immaterial part of man, soul"; under "spiritual" was given "Of spirit, as opposed to matter".

He thought that the Health Assembly, when dealing with such an interpretation of health, must read the word in a spirit - and he stressed the word "spirit" - of real understanding and unanimity. He believed there would be a possibility of arriving at such unanimity if there was sufficient time for dialogue as to what was implied. For himself personally, he thought most would agree that there was a spiritual dimension of man, in the sense expressed by the Oxford Dictionary; whether there could be a spiritual dimension in health care programmes, he was not so sure.

The Health Assembly, said Dr Mahler, had done something very important in raising the issue. He pointed out that in fact it had already been raised by India's designated Member of the Executive Board some years previously, and at that time no response had been given by the Board. He thought it would be possible for the Board, if the Health Assembly so requested it, to come to the next Health Assembly with a resolution that all Member States could unanimously support, and he thought that would be tremendously important. The Assembly agreed to this proposal and referred the issue to the WHO Executive Board.

At its seventy-third session in January 1984, the Executive Board listened to some further reflections of the Director-General on the matter in order to facilitate its discussions on the subject [10].

The word "spiritual", said Dr Mahler, was defined in a variety of ways, all of which have one common denominator. "They imply a phenomenon that is not material in nature but belongs to the realm of ideas that have arisen in the minds of human beings, particularly ennobling ideas. As far as can be gathered from the history of humankind, human beings were moved to action through ideas that arose in their minds. Often, people developed their ideas in order to improve the material world in which they lived, and their lot within that world. This is where Homo sapiens differs from all other known species."

I might add at this point that the President of Bosnia, 'Alija 'Ali Izetbegovic, has expressed this idea as follows [11], and I quote, "Materialism always stresses what is common to animals and humans, while religion stresses what makes them different... While Camus indicated that " man is an animal which refuses to be so", Whitehead saw in this negation the essence of the religious attitude, this "great rejection". Religion seems to say: look what the animals do, and do the opposite, they devour you should fast, they mate, you should abstain; they live in flocks, you should try to live alone; they strive for enjoyment and flee from pain, you should expose yourself to difficulties. In a word, they live with their bodies, but you should live with your spirit."

Returning to Dr Mahler's address to the Executive Board of WHO, he noted that "ideas have often been formed in people's minds following wonderment at the origin of the universe and of life on this earth, giving rise to different religious, moral or philosophical concepts. These in turn have had very practical implications for people's daily lives, such as their rhythm of daily work and rest, their dietary practices, their hygienic habits, their social organization, their marriage laws and customs, their civil and criminal laws, and their treatment of offenders and dissenters.

"By shaping people's actions and ways of life", he said, "such philosophical, religious, moral or political ideologies have had a profound influence on the physical, mental and social well-being of the people concerned. Communities can only become genuinely involved in any endeavour if they do so in ways that are commensurate with their value systems, their beliefs, their attitudes and their customs. Their value systems can express themselves in widely different ways, such as rellgious beliefs and practices, political ideologies; moral sentiments, national, tribal or other group solidarity, the desire to perpetuate local and family traditions and cultural heritage; or concern for the future of the world's environment".

Dr Mahler noted that "the concept of health for all by the year 2000 also arose as an idea in people's minds, against the background of the adverse health conditions of the vast majority of the world's population. It was greatly influenced by such humane qualities as a sense of decency, empathy with the world's health underprivileged, compassion, and the desire for social justice regarding health. Considerations such as these laid the moral basis for the decision of the Thirtieth World Health Assembly in 1977 that the main social target of governments and WHO in the coming decades should be the attainment by all the citizens of the world, by the year 2000, of a level of health that will permit them to lead a socially and economically productive life. Thus, nonmaterial values led to a decision that has significant material value for people".

"The Strategy for Health for All", he said, "is therefore dependent on a number of non-material factors in addition to such material factors as resources. An important feature of the Strategy is the social control of health systems through community involvement. Social control has the potential to make health delivery more humane, to ensure care for people before they become patients, and if they do become patients, to ensure they are treated as feeling and thinking individuals with their own personalities, and not merely as impersonal "cases" or objects with diseased bodily organs in need of repair".

The Director-General concluded his reflections by saying that "it can justly be claimed that people's ennobling ideas have not only stimulated worldwide action for health but have also given to health, as defined by WHO's Constitution, an added spiritual dimension".

The Executive Board concurred with the analysis and conclusions of the Director-General and recommended to the Health Assembly to note the Board's conclusion [12]. In May 1984, the Thirty-seventh World Health Assembly took the historic decision to adopt resolution WHA37.13, which made the "spiritual dimension" part and parcel of WHO Member States' strategies for health [13]. Had this important resolution been expressed as part of the preamble to the Constitution or as a declaration, the vital parts, in the very words of the Health Assembly, might have read somewhat as follows:

• The spiritual dimension is understood to imply a phenomenon that is not material in nature, but belongs to the realm of ideas, beliefs, values and ethics that have arisen in the minds and conscience of human beings, particularly ennobling ideas.
• Ennobling ideas have given rise to health ideals which have led to a practical strategy for Health for All that aims at attaining a goal that has both a material and nonmaterial component.
• lf the material component of the strategy can be provided to people, the non-material or spiritual one is something that has to arise within people and communities in keeping with their social and cultural patterns.
• The spiritual dimension plays a great role in motivating people's achievement in all aspects of life.

The resolution ends with an affirmation that "ennobling ideas have not only stimulated worldwide action for health, but have also given to health, as defined in ~WHO's Constitution, an added spiritual dimension", and invites Member States "to consider including in their strategies for Health for All a spiritual dimension as defined in this resolution in accordance with their social and cultural patterns".

Fourteen years later, the special group of the WHO Executive Board for the review of the Constitution proposed that the preamble be modified to read [14]:

Health is a dynamic state of complete physical,
mental, spiritual and social well-being and not
merely the absence of disease or infirmity

In January 1998, the Executive Board endorsed this proposal of the Special Group and adopted resolution EB 10 1.R2 recommending the World Health Assembly to modify the preamble of the Constitution accordingly [15].

So much for discussions and resolutions. But how has spiritual dimension been taken into consideration by the different levels and regions of the World Health Organization ? And by the World Health Organization we mean the collectivity of its Member States and not merely the Secretariat.

I will take the liberty of giving you an idea, Mr. Chairman, of the way this spiritual dimension is addressed in the region of WHO I know best, the Eastern Mediterranean Region, which, with some exceptions, very largely covers an area more commonly known as the Middle East.

This is a region where, according to the scientist Julian Huxley, "civilization began". He went on to say: "Everywhere, civilization diffused in from somewhere else. Only in the Middle East are to be found the first spontaneous developments of that novel form of human organization we call civilized society".

Of the almost one billion Muslims in the world today, nearly forty percent of them live in the Eastern Mediterranean Region. Christianity also originated in this Region, and its believers are grouped in over 20 different religious communities, such as the Copts in Egypt, the Maronites in Lebanon and the Armenians in Iran and Syria. Judaism also originated and continues to be present there.

Reviews of the development of science often neglect to mention the contribution to that development of Islamic civilization, which comprises the collectivity of Muslim, Christian and Jewish scholars who lived in what is called the Muslim world. Yet according to Marcel Boisart [16], 'Vas it not this very world which collected, translated and commentated upon the writings of antiquity, leaving on them the imprint of its own genius before passing them on to the Western world? Were Averroes (ibn-Rushd) and Avicena (ibn-Sina) along with other Muslim philosophers, not the masters of thought for many generations in Europe?... [Did not] Maimonides, the Jewish philosopher of the twelfth century, whose influence greatly determined the direction taken by the Judaic and Western consciousness in general, live in the land ruled by Muslims?

Or, as the UK Foreign Secretary Robin Cook recently put it so eloquently: "The West owes much to Islam. Islam laid the intellectual foundations for large portions of Western civilization. From our numbers to our understanding of the stars, much of the basis of our civilization is rooted in Islamic learning ... One of the biggest errors the West could make would be to think that Islamic culture is something alien. It is not. Our cultures have interwined throughout history" [17].

It is worth remembering these things if only to note how much the medical community had to regain in order to reach a positive definition of health in the twentieth century. It was a Muslim doctor, Ali ibn Al-Abbas, ten centuries ago, who defined health as"A state of the body in which functions are run in the normal course"[18]. It was Averroes (ibn-Rushd), some 800 years ago, who defined health as "A state in which an organ performs its normal function or undergoes its normal reaction"[19]. And it was Ibn al-Nafees, 700 years ago, who said: "Health is a state of the body in which functions are normal per se while disease is the opposite state" [20].

All the Muslim doctors, then, made health their starting point, while illness was the opposite to lt. This reflected their understanding of what is stated in the Holy Koran:

"…Your gracious Lord ... has created and
formed perfectly and shaped your nature in
just proportions (82:6-7).

"Consider the human self, and how it is formed
in most normal form " (9,1.- 7)

"We have created man in the most perfect
conformation " (95.-4)

From the following verses of the Koran:

"And He enforced the balance.

That you exceed not the bounds,

But observe the balance strictly;

And fall not short thereof ' (55.- 7-9)

the Muslim doctors deduced that "Health means that the body is in a state of dynamic equilibrium" as Ali ibn AI-Abbas said [21]. Avicenna (ibn-Sina) explained this dynamism of the health balance saying: "The state of equilibrium which a human being enjoys has a certain range with an upper and lower limit" [22].

This one example, the definition of health, shows how deeply rooted religious teachings are in the culture of the peoples of this region. In 1987, Dr Hussein Gezairy, the WHO Regional Director for the Eastern Mediterranean, noted in his biennial report [23] that in most countries of the Eastern Mediterranean Region, the spiritual dimension played a considerable role in daily life. The Regional Office had promoted and initiated activities that would help Member States to gain the active support of religious leaders in transmitting health messages to the communities and a programme that sought to identify ways in which religious leaders can aid in promoting Health for All had been initiated. The priority topics were: smoking, water pollution, female genital mutilation, AIDS, environmental health and drug addiction. Smoking was identified as the first of the six priority areas in health to be addressed through concerted activities that were also to involve the media. Investigations and research in Islamic jurisprudence were undertaken by a number of Islamic scholars with regard to the Islamic stand on the issue of smoking habit. Their fatawi (decrees) issued on the subject were used as the basis for producing information and training materials for religious leaders and for dissemination to the public during the planned anti-smoking activities.

The WHO Regional Office, in collaboration with the Islamic Organization for Medical Sciences and the Jordanian Royal Academy for Islamic Civilization Research , convened in 1989 a consultation on Islamic lifestyles and their impact on health development and human development in general. A panel of health professionals, scientists, jurisprudents, religious scholars, educationalists, economists, sociologists, writers, journalists and representatives of the organizing bodies participated. The consultation identified sixty Islamic lifestyles in different areas and verified their relevance to Islam by means of evidence from the Koran and the sayings of the Prophet (peace be upon Him). It then studied their impact on health and human development and discussed various ways and approaches for their implementation in today's society. The outcome of the consultation was the Amman Declaration on Health Promotion [24].

The Regional Office for the Eastern Mediterranean has continued to make use of the influence of rellgious teaching on the peoples of the Region through using such teachings in health education and health promotion. The Regional Office has published a series of health monographs in a series entitled The Right Path to Health - Health Education through Religion. There are currently eight booklets in this series focusing largely on the Islamic position with regard to such diverse health issues as Smoking, water and sanitation, environmental health, healthy lifestyles, circumcision and female genital mutilation and AIDS. This last booklet was the outcome of a consultation in which Muslim scholars and Christian clergy participated and came out with joint views and recommendations. The Amman Declaration also is included in this series, all of which has been translated from the original Arabic into English, French, Pushto, Farsi, Urdu, Somali and Kurdish, while one of the books has also been translated into Greek and Turkish.

Over the years, the Regional Office has worked with other interested bodies, such as the Council for International Organizations of Medical Sciences (CIOMS), the Islamic Organization of Medical Sciences and the Islamic Educational, Scientific and Cultural Organization (ISESCO), in tackling very sensitive issues, such as the role of religion in the prevention, treatment and rehabilitation of drug addicts, the rights of the mentally ill in relation to Islamic law, health education of adolescents with particular reference to sexual education as well as many bio-ethical issues such as organ transplantation, identifying the beginning and end of life, euthanasia; norms for medical practice and for biomedical research involving human subjects; dealing with AIDS patients, genome research, genetic testing and gene therapy; and drug promotion. 1 may be able, Mr Chairman, in this regard, to contribute to the discussions of some of these bio-ethical issues to be addressed during this Symposium.

I hope that this brief outline has given you some idea of the significance of the spiritual aspect of health. Rarely addressed by the medical profession, who inevitably See it as being beyond the scope of their role, it is nevertheless an increasingly important consideration in this modern world of ours. The industrialized countries, so well provided for materially, have witnessed massive rises of the levels of stress, despair, mental ill health and suicide while many developing countries are now beginning to feel the negative effects of marterialism as well as the benefits. lf we can find ways to approach practically the spiritual dimension of health, we may be able to alleviate and combat some of the pressures of modern life.

Thank you.

References

Dr. M. H. Khayat
Deputy Regional Director WHO's Office for the Eastern Mediterranean
P.O.Box 1517
Aleksandria 21511, Egypt