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American Journal of Public Health Research
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The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
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The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
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Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
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Anne Lanham, Lillian Mwanri

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Where is the Global South in the Health Discourse? Attempt Forthcoming from the Oromo People’s Perspective

Begna Dugassa

Oromo Studies Association, Mississauga, Canada

Abstract: Background: The contemporary understanding of health and diseases has evolved from the Judeo/Christian/Islamic literature to the biomedical knowledge and then to the World Health Organization (WHO), definition. All these definitions consistently focused on deficit model and equivocally claimed universality. Although the impacts of injustice to health are well known, these definitions did not give adequate attention to the social and environmental injustices as disease-causing agents. Methods: Having in mind that knowledge is socially constructed, in this paper I reviewed literatures on the evolutionary changes in our understanding of health and diseases and made effort to trace the significant changes made in our understanding health through time and the concepts that are kept in those changes. I also looked at the significance of maintaining the deficit model and universality in disease prevention and health promotion. Results: Although there are changes in our understanding of health and diseases, the contemporary definition has significant deficits. Those definitions are not only incomplete and they are also biased. The definition gives us theoretical underpinning for actions, the contemporary understanding of health hindered us from effectively promoting health. Not only that, these definitions victimized the victim and made the gaps in the life expectancy between countries and within a country as a natural and enviable reality. Conclusions: To effectively promote health, prevent diseases and reduce health disparities we need to widen our way of thinking about health, depart from the Eurocentric ideas and provide theoretical rationales that foster the “upstream” public health approach. In the Oromo perspectives, health and peace are intertwined. For them, personal health/peace are intertwined with the peace/health of the family, community and natural world as well as divine power. For them, peace includes social and environmental justices.

Keywords: Defining health, incorporating social justice and sustainable development in definition of health

Received November 17, 2018; Revised December 22, 2018; Accepted December 31, 2018

Citation: Begna Dugassa, Where is the Global South in the Health Discourse? Attempt Forthcoming from the Oromo People’s Perspective. American Journal of Public Health Research, 6 (6). 243-252. January 2018. doi:10.12691/ajphr-6-6-2

1. Introduction

The highest possible attainable health is the dream of all human beings. Health outcomes are influenced by wide ranges of factors. Those factors have their individual roles and collective play as well as their intricacies interactions. Whether it is big or small, in all corners of the world people have been researching on what constitutes health, evaluate what makes them healthy and how to foster a healthy lifestyle. In all corners, people ask how they can better understand and improve public health. Public health, as implementation science, has developed based on that accumulated knowledge. Given that community needs are dynamic and complex, public health has set its five major goals: a) optimizing healthy human development; b) improving prevention and control of infectious diseases; c) preventing, reducing or delaying degenerative diseases and injuries; d) promoting of healthy natural and built environments; and e) strengthening population capacity [1]. Definition underpins the way we need to understand, approach issues and respond to them. Developing relevant, effective, timely public health policies necessitates giving attention to the experiences of people from the global south in health discourse.

Personal, community and population health are the results of accumulated dynamic interactions of complex biological, psychological, social and environmental systems [2]. The interactions of these complex open systems{1} affect our understanding of diseases because they are based on different geographical locations, culture and socio-economic status. Epigenetic science has made clear that these dynamic interactions include several generations. Converging evidence from epigenetic science taught us that for better or for worse significant events in life act in accumulation to cause physiological disruptions or embedded “biological memories” and lead to lifelong and intergenerational impairment in both physical and mental health [3]. Hence, our understanding of health and disease changes as the contexts and parameters shift with time, age and places. Public health problems are usually multi-dimensional and our understanding of health and disease is therefore socially constructed. Public health policies makers need to identify health problems and synthesize data contextualizing on the knowledge, values and aspirations of the group.

In my previous work, writing about the relationships between free media and public health, I brought to light the story of a young Oromo girl Bultu, who died of a leg infection ([4]. p73). To give context to her death, I purposely presented the story by moving away from the biomedical model. In the story, I asked questions and gave simple possible answers:

“Why did Bultu (12 year old girl) die? Because she had a bad infection in her leg.

But why did she have this infection? Because she had a cut on her leg that got infected.

But why did she have a cut on her leg? Because she was collecting leftover food in the Addis Ababa (Finfinne) city junk, and there was some sharp broken glass that she fell on.

But why was she collecting leftover food in the junk? Because her family is poor and they could not provide her with food.

But why couldn’t the family provide her food? Because they had lost their farmland and moved to the city.

But why they could not find a job in the city? Because they do not speak Amharic and they are illiterate. But why weren’t they educated? Because school courses were only given in Amharic, and were only available in cities and towns.

But why wasn’t the language of instruction in Afaan Oromo? Because the Ethiopian government does not recognize the Oromos as their own citizens.

….. Who is responsible for the death of this young girl—Bultu?

But why...?”

In this paper, I ask questions that Bultu would have had asked if she were still alive. If my family is evicted from their home and “the business entrepreneurs” took over their land, is this just a business venture as usual or an infirmity and an invisible killing? Who has the authority to define health? Whose experiences count as evidence in defining health? Why are public health researchers, policymakers and practitioners not more vigorously making efforts to promote social justice and recognize that racial/cultural/gender dominations are disease or causing conditions? Who should know what makes me sick and healthy? These questions are real, they are more than an intellectual exercise and social ills need to be paid attention to and require practical answers.

Human beings are heavily socialized and as a result, rightfully or wrongfully they continuously connect ideas and make efforts to establish the cause and effect relationships. Social theorists and public health researchers [5] forcefully present the idea that theories inform practices and practices inform theories. Theories provide the lenses through which we can see and make sense of the situation. Using theory, we generate ideas and explain the “what”, “why” and “how” questions. Using theory we justify our actions and inactions, explain practices and lead the society. Societies understand health and diseases, and inform policymakers to name the causes of the problems and identify the social conditions; these steps are needed to reduce the risks and improve the population’s health. For example, in the English language the term health comes from the word – hælþ which means wholeness, being whole, well or uninjured. This concept is consistent with the worldview of English speakers. For indigenous Canadians, health is understood in historical, cultural and social context. For them, health is inseparable from belonging to their ethno-cultural identity. Indeed, for the Cree people, the term health is “being alive well” and the concept is not about physiological conditions, but daily living, cultural activities, the balance of social relations and quality of life [6]. It is clear from this that our understanding of health and diseases are socially constructed.

Let me put things in perspective. Words do not have meanings. We assign meanings to the words by connecting them with our own “prior knowledge, values and aspirations”. Our concepts are based on our socio-cultural-environmental realities and hence they are different in diverse settings. As we can see later in detail, the contemporary working definition of health is based primarily on Euro-centric ideas. Definitions are made based on prior knowledge and values and serve the interests of those particular cultural groups that produced the definition. Clearly, power is exercised when the meaning of health and disease are presented as a universally accepted term. The inability of the global south and marginalized groups to contribute their perspectives in defining health has contributed to health disparities. The population health researchers and policymakers need to critically reflect whether or not the contemporary definition of health and disease guarantees equity in health or legitimizes health disparities.

What I am attempting to do in this paper is prove that the dominant definition of health is not value free. The definition does not encompass peace, social and environmental justice and collective rights. As my entry point, I make the case of Oromo people the center of my discussion. Since the 1880s, the Oromo people have been under the Ethiopian colonial rule. In their colonial conquest and the maintenance of domination, the European empire builders have provided the supports needed to the Ethiopian regimes [7]. For over one hundred and thirty years, the Oromo people have been destabilized, individual and groups rights have been violated, and they have been collectively denied the right to decide on their social, economic, political, cultural and environmental affairs. The Oromo people have been deprived of the right to live up to their potentials and this conditioned them to live in ill health, and contemporary public health theories and practices are silent and even indifferent. As I write this paper, over a million Oromos have been evicted by the Ethiopian government from their homes, simply because they are Oromos. Such widespread evictions constitute the textbook definition of ethnic cleansing. While this eviction was going on, the world community elected Dr Tedros Adhanom the key decision maker in the Ethiopian government to lead the World Health Organization (WHO). The current definition of health does recognize war, instability, human rights violations, ethnic cleansing and genocide as population health concerns. The election of Dr Tedros Adhanom to the WHO, who has personally involved in creating unhealthy social conditions for the Oromo people{2}, is particularly revealing of the longstanding systemic problem.

It is evident that health and diseases are manifestations of the long-term complex interactions of social conditions. As said before, our understanding of health is socially constructed and this makes our understanding of health problems complicated. For example, in the Judeo/Christian/Islam literature, life on earth is less important than life after death. Life on earth is seen as a preparation for eternal life with the divine power in heaven. The conducing conditions for eternal life were seen as conducting one’s life with duties indicated in the Holy books Torah/Bible/Quran. The teaching of these books does not encourage members to give enough attention to their social problems on earth, or of making the utmost efforts to guarantee the best possible conditions in life. In the little attention these teachings give to life on earth, health is seen as the endowment from a divine power that does what it wishes. These teachings made religious leaders healers and intermediate health granters.

The little attention these teachings give to life on earth did not prepare societies to make continuous efforts to understand their problems and solve them. Not only that- the teachings focused on life after death in faraway places “heaven or hell”. These teachings are not preparing societies to care about their natural environments. Instead, the teachings inform the members not to pay attention to their natural environment and indirectly provided theoretical reasons to pollute the natural environment.

In the Western world, as knowledge of bio-chemical sciences progressed, the concept of health has slightly changed. Societies started to focus more on issues surrounding life on earth and having better social conditions and widening their choices in life. This social transformation provided theoretical reasons for the European empire builders to colonize the lands and people of other countries. As the colonizers anticipated, colonialism widened their choices in life and in its turn colonialism limited the choices of the colonized people. Although the colonial agenda is currently challenged, many of the colonial ideas and practices are still in place. Defining health from the Eurocentric perspective hinders the progress in the life expectancy of marginalized groups. Equitable access to the social determinants of health is fundamental to improving the health of indigenous people and other marginalized groups and this necessitates redefining health. The definition, I propose in this paper provides theoretical rationales to tackle the cause of the causes of diseases and foster the “upstream public health approach”.

Following the introduction, in the second part, I introduce the objective of the paper, explore the definition of health from the Oromo perspective and explore the theoretical reasons for searching alternative definitions. In the third part, I explore the missing opportunities in promoting diseases and promoting health. In the last part, I provide discussion and conclusions.

1.1. Objectives

As the epigenetic science now revealed, significant events in life act in accumulation to cause physiological disruptions or carried out “biological memories” and lead to lifelong and intergenerational impairment in both physical and mental health. This means improving the health of the population in general and the health of the marginalized groups in particular requires giving attention to the “causes of the causes” of diseases. Creating better social conditions for health necessitates thinking outside the box. In understanding that the definition of health provides a framework of thinking in researching, analyzing, setting policies and as well as in implementing, the major objective of this paper is defining health from the Oromo perspective. This definition fills a major gap in our understanding of health and disease and widens health people’s choices in life. The second objective is to introduce the Oromo concept of health- that for them it is a state of balance, harmony and wholeness and is coherent with the public health cutting edge – systemic thinking and promoting an ambitious public health agenda.

1.2. Politics of Definition

Ideas are contagious and often societies reproduce concepts and ideas intentionally or otherwise. This means, if we reproduce theories and practices without scrutinizing them, we might legitimize injustice. For this reason, before I define health, I want to briefly explore politics in definitions. According to the Webster Dictionary [8], the term definition comes from a Latin word –definire – and it means set-bound. Setting a bound undeniably conveys normative. Definitions can be categorized into two major categories: intentional and extensional. The intentional definition is geared to give the essence of the term by specifying conditions when the term should be used. An extensional definition is a term used to formulate meaning by specifying its extension. If definition set-bounds, it gives theories or reasons for action or inaction. Through definition, the politics of meaning setting are exercised. By definition, we appoint what is “real and/or unreal” and what to do and how to do it. In doing that, theoretically unjust and practically unfair normative can be imposed and societies are oriented to develop behavior toward the meaning. Indeed, the goal to search for alternative thinking is our definition inform our action.

1.3. What Inspired Me to Define Health from the Oromo Perspective?

First, the public health system has strived to make the foods we eat, the water we drink and the air we breathe safer. It also made our foods nutritionally balanced and reduced diseases caused by nutritional deficiencies developed vaccinations and partly controlled communicable diseases. The development of antibiotics further reduced the cause of death from infections. In addition, through health education and disease prevention, it has delayed the emergence of chronic diseases and improved life expectancy. However, public health did not make adequate efforts to bring social stability, social cohesion and safe and equitable social conditions. More importantly, it did not put forth cutting-age knowledge to create supportive social condition to social and environmental justice. This makes public health intervention in effective.

Second, I am influenced by the literature in knowledge construction and knowledge synthesis in public health. The knowledge synthesis methods include compelling inventory of public policies, developing the intervention logic, synthesizing data on the effects of the policy, enriching and contextualizing data [9]. These methods make it clear that public health researchers need to deliberately look at the data through the actor’s lenses and enrich the framework of thinking, having in mind widening people’s choices in life and improving a population’s health.

My third, justification is that definition gives normative and theoretical reasons for actions or inactions. As I have presented in my previous work [10] theory gives the lens through which we can see, explain and address social problems. Indeed, to theorize is to use our mind’s eye and systematically observe and articulate reasons to our actions. Through definition, power is exercised and by that the dominant groups validate their needs and aspirations and invalidate the needs and experiences of others. For example, in my previous work, I have discussed the ways the Oromo concept of black and blackness is distinct from the European concepts. In the Oromo concept, black and blackness represent purity and holiness (bishaan guracha=pure water; Waaqa Guracha = holly God) and holiness, whereas for the Europeans black and blackness is conceptualized in negative terms –Black Death, black market, and blacklist. Interpreting data in distinct ways is a process as old as our human civilization.

Diverse views and perspectives are natural. Indeed, the psychological underpinning of differences in those language concepts underlines variances in our worldviews. However, the problem is when the perspective of one group is imposed upon the other. Social reasoning is constructed on our prior knowledge and it is deeply settled in our belief system. Those who believed that black and blackness represent “purity” and “holiness” are most likely to see black persons in positive terms. However, those who conceptualized black and blackness in negative terms-with phrases such as “black death”, “black market” and “blacklist” - are most likely to see black persons and community negatively. This explains why the slave trade more targeted black people and persisted longer. Indeed, this has contributed to the differences in the Western world in terms of life expectancies and poverty levels among the blacks and whites. The problem with the language of dehumanization is that it provides theoretical reasons to normalize persecution, impoverishment and the inferior social conditions. At the societal level, a small change can have bigger effects. This necessitates the need to identify biased concepts or ideas that are framed with no consideration for the perspective of marginalized groups. Ideas and ideologies and concepts that are contrary to principles of human rights and equity need to be interrogated and challenged.

Across the culture, race, gender and social status, health and quality of life are one of the most treasured commodities. Redefining health can lead to widening our understanding of health and diseases. In turn, widening our understanding of health and diseases can instigate different methods of care, disease prevention strategies and health promotions tools. Widening the definition of health does not represent increasing costs. On the contrary, it is about fostering disease prevention methods and effectively utilizing health promotion tools.

Fourth, the contemporary policymakers widely claim their decisions are evidence-based. Evidences could be derived from the cultural, political, social and technical rationales [11]. This means what constitute rational for one is not rational for the others. When the dominant definition of health was given by the WHO [12], many countries were under the colonial rule. This means the definition is based on the Euro-American rational. The needs, perspectives, aspirations, understanding, and values of colonized people were not incorporated. This made the understanding of health and diseases incomplete. More of the same will not suffice to achieve our ambitious public health goals. To broaden the scope of our understanding of health and diseases, widen people’s choices in life and exercise the principle of self-determination of people that were not involved in defining health, we need to make known the shortfalls of the WHO definition.

1.4. Theoretical Reasons in Search of an Alternative Definition of Health

Knowledge is socially constructed [13] and it is a form of contextualized thinking and doing. Because knowledge is a contextualized thinking, it is dependent on prior knowledge [14]. Eurocentric knowledge focuses on analytical tools and it encourages breaking down the problems and assembling them in finding solutions. Using the reductionist scientific research has focused on breaking down problems and assembling we have learned what is going on at molecular, cellular, tissue and organ levels. Although such scientific knowledge helped us to understand what is going on at the molecular, cellular, tissue and organ level, it has failed to help us understand the complex interactions between cells, tissues and organs at the systemic level. To appreciate the proposed definition, one needs to move away from the reduction science and adhere to systemic thinking. Systemic thinking promotes the need to understand complex interactions between social, biological, psychological and environmental conditions of health. The proposed definition, on one hand, it creates a climate that empowers people and generates optimum social conditions for health. On the other, it gives the essential tools needed to contemporary public health leadership that promote the essence of systemic thinking.

The most comprehensive review of research in knowledge construction in public health reaffirms that our knowledge is socially constructed. Knowledge is dependent on the social location of the knowers. The contemporary school of thought is overwhelmingly driven to seek universal truth or knowledge. Using reductionist methods to do that means that power of the dominant group is exercised. The exercise of power in validating knowledge has validated and commercialized the experiences of the dominant groups and invalidated the experiences of the marginalized. The marginalized groups’ needs and aspirations have been left with no or little recognition. In other words, the social problems that are relevant to the dominant groups are recognized and these have informed researchers and policymakers to find working solutions. The social problems of marginalized groups are understood from the perspective of the dominant – and undermined their needs. As I have noted earlier, misrecognition inflicts serious harm.

In the Western world in the last hundred years, life expectancy has increased by over 30 years. Improvements in life expectancy have been achieved through a) monitoring the health status of the community; b) investigating health problems and hazards; c) informing people about health issues; d) mobilizing the community to identify health problems; e) developing policies and plans that support community health; f) enforcing laws that protect health and ensure safety; g) linking people to personal health; h) assuring a competent public healthcare system; i) evaluating the effectiveness of health services; j) researching innovative solutions to health problems [15]. Although there has been some progress in the life expectancy of marginalized groups, the gap between them and the dominant group remains unacceptably high. For example, in Australia, the gaps in life expectancy between the indigenous male and the rest other male population is over 17 years. For Canada and New Zealand, this gap is over seven years [2]. Theories serve as a foundation and structure from which public health policies and practices can be developed. Theoretically, if health had been understood from the perspective of the marginalized group, many of the social ills they experienced would have been addressed.

Currently, public health is functioning on the understanding that the determinants of health vary. These identified determinants of health are social, cultural, physical and physical and biological conditions. Health promotion advises the need to create healthy social conditions. Human rights activists present a strong link between human rights and health and promote the rights of people to be respected. Historically, the social determinates of health and the rights they promote have been framed in the Eurocentric ideas and these views freed the dominant group from being guilty. Although contemporary public health clearly affirms the importance of the social determinants of health, it avoids mentioning the ways the dominant group have created and are creating unhealthy social conditions among the colonized and marginalized people. The rights they promote are the rights of individuals framed in the protestant ethics rather than the collective rights (social, economic, political, cultural and environmental) that encompass the views of indigenous people and collectively protect them from all forms of violence.

The relationships between human rights and health more clearly manifest when we closely look at the impacts of violations of the social, economic, political, cultural and environmental rights. For example, policy-makers need to make assessments, develop policies, and provide assurance. Assessment includes identifying contemporary needs and foreseeing emerging risks. Policy development is prioritizing needs and developing programs. Assurance is evaluating if the program is achieving the desired goals, evaluating and monitoring policies. All are determined by political decision- making and the definition, or by the goals they want to achieve. This means if marginalized groups are not in a position to define the goals and set policies we cannot prevent health disparities.

1.5. Historicizing the Definition of Health and Diseases

History is a highly useful tool for public health. Closely looking at the historical changes in understanding health and diseases, we can trace the social changes that informed the transformation and the stages of changes. Public health policies do not appear out of the blue and understanding public problems are the heart of policy-making [16]. The connection between the interests of the ruling class, morals and hygiene has been very common throughout history and has been applied to all sorts of problems [17]. For example, in the Judeo/Christian/Islamic literatures, health is seen as a gift from the divine power. The literature teaches that to be healthy one needs to have faith in the divine power and be obedient to its teaching and their agents. That teaching encourages their followers to hope for paradise in life after death (heaven). These teachings underline that having the right ethics and morality frees people from misery, disease and provides healing. The assumption of these teachings is that the culture and worldview in which the literature has developed has valid knowledge. Out of a deep belief in such assumptions, the colonizers travelled thousands of miles to convince others that they have a valid knowledge that legitimized their higher social status and exploited the human and natural resources of the colonized people. The colonizers justified their colonial agenda as a civilizing mission –mimicking that their policies have healing motives and power. However, from the colonized people’s perspective, the colonizers have acted as disease-causing agents or have created unhealthy social conditions [21,22].

The first major critique of such an understanding is that the definition says that if you want to be healthy, you need to validate the culture and worldviews of those who have developed those literature and worldview. Indeed, such a concept provided the theoretical reasons for the colonizers to conquer the people who have had different worldviews. Even today, many countries of the Western world and the Middle Eastern Countries are spending billions of dollars to validate their own knowledge and experiences and invalidate the knowledge and experiences of others. The genesis of such a desire comes from the long-held belief that they have valid knowledge. The policy makers of these countries do not realize that imposing their knowledge and experiences upon others depreciates the needs, experiences, and aspirations of the marginalized groups. In addition, such practices indoctrinate people and provided what Jalata and Schaffer [18] referred to as false conciseness [1] and was responsible for their self-depreciation. For example, when these teachings propagate their idea of “ethics” and that following the teaching of their “Divine power” is essential to be a complete person, they are legitimizing their knowledge and power. On the other hand, such a teaching informs the colonized people that they have a “deficient culture”, “deserve inferior status” and makes them responsible for their poverty and ill-health. It is for the same reasons that the people who have been living in their own “ethics” worldview are categorized as “pagans” or “sinners” and even referred to as “the sick”. In several cases, the ethics of the colonized are actually much better than the colonizers. Such dominant teachings have hindered the self-fulfillment and self-actualization of the colonized people.

Indeed, when the European empire builders referred to the colonized people as “uncivilized” “sinners” i.e. the sick, they are implying that their knowledge and worldview has healing power and that the experiences of the colonized people are invalid and sickening. Indeed, the colonizers made the colonized people "guilty" when they described them as sinners. The notion of civilized and uncivilized implies that the empire builders have superior ethics, morality, and knowledge. The colonized people who have had their unique morality and ethics are seen as sinners. Misrecognition is not just a lack of due respect- it can inflict wounds on individuals and groups. If the colonial teaching convinces the colonized people to feel guilty, it inculcates self-depreciation and even self-hatred which can have crippling effects.

Second, the definition misreads the idea that our health is determined by the dynamic interaction of our biological, psychological social and natural environmental systems. It misses the critical role of the conditions in which we live and work on our health and diseases. Indeed, the definition freed the colonizers who took away the human and natural resources of the colonized people, made them feel guilty, depreciated their power and left them in poverty and disease from taking any moral responsibility.

The third critique is that it discourages societies from making continual efforts to create healthy conditions. For example, when the first Kenyan President Jomo Kenyatta said, “When the missionaries arrived, the Africans had the land and the missionaries had the Bible. They taught us how to pray with our eyes closed. When we opened them, they had the land and we had the Bible” [19], he was implying that such colonial teachings are deceptive, illegitimate and unsuitable for the colonized people. Instead of teaching the people to critically read their social world, it is intended to produce silent and submissive citizens. It is unhealthy.

The fourth critique is the failure to conceptualize the role of our natural environment on health and diseases. Those definitions and teachings failed to mention the ways the natural environment influences health and diseases and the need to care about our natural environment. Fundamentally this hindered societies from better understanding their social problems and solving them.

1.6. Biomedical Definition of Health

One of the most influential definitions of health is outlined in the biomedical terms. The biomedical terms emerged following the far-reaching progress in the biochemical sciences. The biochemical sciences present themselves as if it is acquired in a value-free and objective research. It appears as if it is neutral and the only valid knowledge. Although the definition of health given in the biomedical model has slightly moved away from the Judeo/Christian/Islamic literature, it also focuses on a deficit model. The biomedical model presents disease as the defects, or dysfunctions of (cells, tissues, organs, and body). The biomedical sciences have been shaped by the social forces and in the recent past, it has openly presented the “black race” as inherently “cognitive deficit” [20]. The biomedical model dominates the contemporary understanding of health and public health policy development. The definition has made the social aspect of public health a secondary matter.

There are three major critiques of the definition of health using the biomedical model. The first critique is that knowledge is socially constructed and the biomedical model is developed in the Euro-American labs and it does not fully capture the realities of others. Indeed, when the definition is focused on the deficit model, it is evident that the knowledge produced in the Euro-American lab is validating their former knowledge where “disease is equated to the sinner—deficit in morality and ethics”.

The second critique of the definition is that it leaves no room for the social and behavioral dimensions of disease and health. This model does not recognize those social ills such as poverty and domination cause diseases. It does not recognize that colonialism is a disease by itself or is at least a disease-causing agent.

The third critique is it captures diseases when it is too late. Instead of identifying the causes of the causes of diseases at the early stage (i.e. colonization, racism, dehumanization and poverty) it captures only when these social ills are manifested at the biological level. It captures diseases when they manifest at the cellular, tissue and organ level. This approach has hindered the development of knowledge in the prevention of diseases and health promotion. In addition, such knowledge conditioned us to spend our resources on clinical care that is too expensive compared to the prevention that focuses on the public good.

1.7. Definition of Health by the WHO

In its constitution, the WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [12]. To its credit, the WHO goes on to state that health is “a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector". These definitions clearly suggest that health does not exist independent of physical, social, economic and political environments. In the minds of the Euro-American scholars, the WHO definition of health revolutionized our understanding of health and diseases. However, from the perspective of anti-colonial thinkers, the definition is facing several critiques.

The first critique is it does not acknowledge politics in the definition of health. Failing to acknowledge politics in the definition means that it portrayed the definition as neutral and therefore universally acceptable. When the definition of health was formally given by the WHO, many countries were under colonial rulers and millions of people were exploited and dehumanized. It did not mention in the definition that the colonial power relations and the denial of the right of people to self-determination are diseases or disease-causing conditions.

The second critique is imitating moving away from the Judeo/Christian/Islam literature and the biomedical deficit model- it recounted those old concepts when it underlines that health is "complete mental, physical and social well-being". The concept of completeness is derived from the Judeo/Christian/Islam literature of complete human and the biomedical concept of defects or dysfunctions. Such a definition left the Judeo/Christian/Islam concept of health to persist and propagated the importance of medicalizing social problems. The concept of complete suggests that when people feel unwell they should simply seek medical help.

The third critique is since 1948 the nature of diseases has been dramatically changing. When the WHO defined health, the major causes of morbidity and mortality were infectious diseases. With the development of vaccinations and the discovery of antibiotics, the impacts of infections are declining. Now poor social conditions and climate change are becoming the major public health problems. In addition, the gap in life expectancy between the affluent and the marginalized poor is expanding. The definition did not fully capture the role played by environmental health and social justice on health and diseases.

Widening discourse in health gives us windows of opportunities to enrich our knowledge and provide us reasons to work with people rather than work for people. In order to widen the efforts we make in preventing diseases and promoting health, it is necessary to revisit our understanding of "health and disease” and reformulating them. My argument in defining health from the Oromo perspective is to use it as an entry point-because in the definition, the Global South are missing. Second, the Judo/Christian/Islamic and the definitions given by the WHO are not providing theoretical rationales to tackle the cause of the causes of diseases and foster the “upstream public health approach”. Without romanticizing, I am arguing that understanding health from the Oromo perspective helps the Oromo people and others to effectively identify the social conditions that are essential to promote health and build their capacity or distinguish conditions that expose them to diseases and tackle them. As I have stated above, a definition is not just providing words or phrases, it is a meaning-giving process. Given that knowledge is socially constructed, a definition must be also a political statement that has profound impacts. I am aware that this definition is set to better serve the Oromo interests.

The way we define health informs our design for intervention and evaluation. The Judo/Christian/Islamic, biomedical and the definition of health by the WHO are framed by the Eurocentric paradigm and those set meanings are anticipated “downstream” interventions. The problem with those definitions is, focus on the “downstream” intervention prevent us from thinking and acting in “upstream”, where small intervention result in substantial change. Indeed, the goal of the search for alternative thinking about health is our definition inform our actions.

1.8. Defining Health from the Oromo Perspective

Colonialism is seen as a disease because it took away the freedom, pride, aspiration and morality of the colonized people [21]. Others say colonialism is a disease-causing agent, because, it took away the human and natural resources, created unhealthy social conditions and exposed the colonized people to the old and new diseases [22,23] and hindered resiliency [24]. Colonialism is not necessarily about the settlement or the presence or absence the colonial military, it is about the presence and absence of the colonial ideas [25]. This means freedom from colonialism and the highest attainable social wellbeing can be achieved if the ideas and ideologies that do not promote social injustice and sustainable development are challenged.

Many anti-colonial scholars have been questioning the motives of the teaching of colonial ideas and challenging its validity. An Oromo scholar who deeply understood the ways the colonial ideas settle in the minds of the colonized people and hinder people’s self-steam and self-regulation and hinder social transformation gave a wise advice as she stated:

To those who despise our ancestral heritage because you see it as backwards- I say I relate to your struggles…. I despised my heritage because I was taught it was heathen, pagan, savage, backward and what not… The world that destroyed our ancestors’ ways did not give us a better way of being in the world or relating to others. It just imposed its own…. Your culture is one of the finest and most profound ways of being in the world ([26], p.8).

Profoundly, the wise words of Kumsa [26], Said [25] and others suggest the need to question the validity of the colonial settlers’ ideas.

As I have stated above, a definition is more than putting what we know into words or phrases. In the Oromo worldview, nagaa (peace) and fayya (health) are interwoven. The concept of peace is not separable from haaqa (social justice), tasgabbi (social order) and having harmony with a divine power. In the Oromo worldview, to be personally at peace, there needs to be peace in the family, and with neighbors and a stable social order in the community and peace in the natural environment. This makes peace an essential condition for personal health, community health and public health. The Oromo people deeply value peace and consider any covert and overt assaults on peace is an attack on personal health, community health and population health.

For the Oromo people, health and peace are intertwined. For them, personal peace is good for the person’s health, while peace in the family, community and the natural environment, as well as harmony with divine power are also important. For them the concept of peace goes beyond the absence of war- it includes social justice, having a dignified and worthwhile life. For example, the concept of personal peace encompasses personal dignity and stable mental health. For them, social justice is about freedom from fear, social security, risk reduction and health promotion. The Oromo concept of peace in the natural environment represents the contemporary scientific term of “environmental health”. Indeed, when the Oromos are greeting they wish to each other abundance of peace (nageenyi badhadhaa). When they are referring to social order and harmony with divine power, they are implying social stability, social cohesion, spiritual health, an equitable society and law and order.

Like DNA is a blueprint in the living organisms, the worldview of a society represents who they are, what they value and whom they want to be. The worldview of a society serves as a lens through which they see and interpret the nature of reality and purpose in life. For example, in the Oromo worldview life after death is in his/her vicinity, with the natural environment. The Oromo worldview promotes to live in the paradise in the life after death, everyone needs to be at peace with the natural world. Not only that they believe that the dead communicate with those who are alive through those especially annoyed individuals known as “ekker dubbistu”. They also believe that the spirit of the dead makes a family visitation on holidays. The spirit of the dead expects from the loved once, maintaining peace in the family, community and the natural world. Driven from such theoretical reasons when a loved one dies, family members’ and friends plant trees. This gave theoretical reasons to the Oromo people develop policies and practices to live harmoniously with the natural environment.

In short, from the Oromo perspective, health is a state of balance, harmony and wholeness. Imbalance in personal peace, in the family, community and in the natural world as well as disruptions in the relationship with divine power, constitutes ill health. This signifies that for the Oromo people the sum of the whole (personal peace, peace in the family, peace in the community, peace in the natural world and harmony with divine power) is greater than the parts.

For the Oromo people, the importance of peace to health is straightforward. They noticed that war and instability concurrently occur with diseases. Conflict exacerbate or propagate disease burdens. For example, in 1887 the Italian army stationed in the Eritrean port brought cattle infected with Rinderpest virus. The Abyssinian army invaded the camp and took the animals and unwittingly brought the diseases to the highlands of Eritrea. This resulted in famine in Abyssinia. At that time Abyssinia was waging colonial war in Oromia. Soon the rinderpest virus reached Oromia. The colonial war compounded with the cattle disease disseminated Oromo institution and led the death of two-thirds of the Oromo people [27]. Indeed, in the 1980s the widespread human rights violations and war have also contributed to HIV/AIDS in Oromia [28].

Recent research has established that although the Oromo concept of health involves clinical care, it emphasizes health promotion and disease prevention. In their prayers, the Oromo elders say “isa dhukubsate fayyis” – cure those who are sick. Oromo indigenous clinical care includes herbal remedies, physiotherapy, psychotherapy and even surgery.

In their prayers, the Oromo people emphasize the need for health promotion and disease prevention. Prevention includes vaccination. The Oromo oral story suggests that they have developed vaccinations for smallpox, rinderpest virus and rabies. In their prayers they say,

“Isa deeme nagaan galchi” - Let those who are travelling come home in peace

Dhukkuba hamaa nuraa qaabi - prevent us from epidemic diseases

Beela hamma nuraa qaabi - prevent us from extreme poverty/famine

Waraana hamaa nuraa qaabi -prevent us from a violent war

Nagaa nuuf roobi - give us not stormy rain

The ways we understand health and diseases should inform policymakers what needs to be done to enhance the population’s health and how to do it. Clearly, if the Oromo people were empowered in their affairs they would have developed more skills in addressing the population’s health. If health is understood from the Oromo perspective, the health of the population would have been more vigorously promoted- as well as human rights, social justice and environmental health.

2. Incorporating Definitions

Adelson ([6], p.4) explains the deficit in the contemporary definition of health: “I am not suggesting that physiological wellness is an undesirable or unattainable goal.” In parallel with Adelson’s words, I am not implying that the biomedical model does not capture disease or does not trace the symptoms at cellular, tissue and organ levels. However, as a public health practitioner and researcher, my argument is that capturing diseases when they manifest at molecular, cellular, tissue and organ levels are too late. At that stage, the opportunities and the tools we have to improve individuals and population health are significantly diminished. As I have said above the definition does not provides theoretical rationales to tackle the cause of the causes of diseases and foster the “upstream public health approach”.

There is evidence that theory informs practice and in its turn practice guides theory. As I have stated above, the definition provides the lens through which we can see and understand the problems and find workable solutions. As we know, health policy-making constitutes agenda setting, policy formulation, developing action plans, implementing and evaluating policies. Agenda setting is about what to focus on, policy formulation is what to do about it; action plan is how to do it; implementing is fulfilling the plan and evaluation is about analyzing the impacts. The necessary measures taken in all those steps are directly depending on the set definitions of health and diseases [29].

Clearly, health and diseases are the results of accumulated complex interactions of biological, social and natural environments, and that health disparities are the manifestations. This means that finding appropriate terms that can universally capture health and disease is practically impossible. Indeed, trying to find a universally acceptable definition of health is unreasonable. Based on the objectives of the intervention methods we need to categorize health into three different areas: Primary Health, Secondary Health, and Tertiary Health.

Primary health is the concept that is intended to achieve better population health. It is driven to enhance the public good. Primary health is seen in its relation to social justice, collective and individual rights and environmental health. Given that primary health focuses on the prevention of diseases and promotion of health, it focuses on creating healthy social conditions and addressing social ills.

Secondary health is intended to achieve clinical care. It is consistent with the biomedical model. Secondary health primarily focuses on the biomedical model and it fosters the development of clinical- pharmaceutical and individual care.

Tertiary health is intended to help in the recovery of patients or slow down disease progression. Tertiary health should combine both the primary and secondary care.

3. Discussions

Perhaps the best way to present the idea that health and diseases are socially constructed, one needs to closely look at the social determinants of health. There is overwhelming evidence that health and illnesses are more clearly determined by the social realities than individual factors. This means that the illnesses we get are the manifestation of our social ills, showing at the molecular, cellular, cell, tissue and organ levels. Those social ills are beyond the capacity of an individual to address them. That is the reason public health is seen as a public good, the pursuit of which is not possible without ground rules for coordinated action and the participation of the members. Colonial social policies, such as the denial of the rights of the Oromo people to decide on their social, economic, political, cultural and environmental affairs, have limited their choices in life and hindered their capacity to solve their problems [30,31]. The Abyssinian colonial government has deliberately dismantled Oromo social, economic, political and cultural institutions. This has not only limited the choices of the Oromo people in life, it has denied them the right to develop their own institutions and leadership. These institutions would have identified health risks and set up strategic plans for disease prevention, health promotion and improved life expectancy. In short, the Ethiopian government has prevented the Oromo people from finding their own solutions to their own public health problems. If the concept of health was defined as it is proposed in this paper, the global community would have challenged the Ethiopian government on any policies that are contrary to the definition.

Let us closely look at whether the definition itself influences policy- making. Policymaking is done in the understanding of the problem and searching for workable solutions. On the one hand, policymaking is about identifying emerging social problems and paving directions in which the problems are either prevented, or the damages are reduced or contained. On the other, it is identifying emerging opportunities and directing organizations and societies. Practically it is directing people to the pathways in which they can achieve the best attainable health. Although cost reduction is one of the key components of policymaking, it is more than that. The definition gives theoretical reasons for action or inaction and it is the starting point of policymaking.

Policymaking requires the skill of critically analyzing and understanding the emerging social problems and opportunities. It requires the skill of connecting the puzzles and constructing knowledge from the past experiences. Always the connections are made on the established theories and this makes the definition of health contestable. Setting social policies from the perspective of marginalized groups of people is helpful in finding inclusive solutions. This necessitates understanding that the needs and aspirations of stockholders are essential components of policymaking.

Through definition, the dominant group has validated its power and knowledge. What people recognize as important to themselves is to great extent determined by their place in society. This makes policymaking not a neutral action. Indigenous people and other marginalized groups have for generations been experiencing discrimination in accessing the complex range of the social determinants of health. Changing discriminatory practices should start by defining health from their perspectives.

4. Conclusions

This paper made critical theoretical inquiries in health discourse and conclude the following. First, public health overarching goals in health promotion and disease prevention is socio-culturally acceptable and financially feasible ways of widening people’s choices in life and improve quality of life. Promoting health, preventing diseases and reducing health disparities necessitates widening our way of thinking about health, asking ourselves whether or not we are doing things the right way and reflecting if the way we are defining health affecting our work. In order to bring the greatest impact for the greater number of people focusing on the “upstream” public health strategy is essential.

Second, understanding health through the Judeo/Christian/Islam literature, biomedical model and the definition given by the WHO are framed in the deficit model. Deficit model gives the rationale for clinical care. It is reactive, curative and deals with individuals and too expensive. Its role in reducing health disparity is limited.

Third, in the Oromo perspectives, health and peace are intertwined. For them, personal health/peace are intertwined with the peace/health of the family, community and natural world as well as divine power. Peace includes social and environmental justices. Such understanding provides theoretical rationales for “upstream” public health actions and fixes the problem at its sources, act early and develop healthy social policies. It promotes environmental stewardship.

Abbreviations

EPRDF – The Ethiopian People’s Revolutionary Democratic Front

CDC - The Centers for Disease Control and Prevention,

DNA- deoxyribonucleic acid

Declaration on Conflict of Interest

I researched this topic to address the gaps in the literature. I did not receive funding to conduct this research. No conflict of interest. Require no ethical approval and/or consents.

Notes

1. Open system is a condition in which population’s health depends on the interactions between its social, biological and natural environments.

2. Recently the Ethiopian government has apologized to their wrongs to the people. Indeed, the newly appointed Ethiopian Prime Minster Abiy Ahmed, Ph.D., officially admitted in the parliament that the EPRDF government had perpetuated state terrorism.

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