What is Health

Health is something of an enigma. Like the proverbial elephant, it is difficult
to define but easy to spot when we see it. ‘You look well’ stands
as a common greeting to a friend or a relative who appears relaxed,
happy and buoyant – ‘feeling good’. Any reflection on the term, however,
immediately reveals its complexity. The idea of health is capable of wide
and narrow application, and can be negatively as well as positively
defined. We can be in good health and poor health. Moreover, health is
not just a feature of our daily life, it also appears frequently on the political
landscape. Health scares such as BSE/CJD, SARS and even the
prospect of bio-terrorism have all exercised politicians and their medical
advisers in recent times, and have all provided a steady stream of media
stories. Health risks seem to proliferate, even if, for most of us most of
the time, these are less than urgent concerns.
In all such instances, and in our more mundane experience, health is
also related to other complex ideas such as illness and disease. This constellation
of terms: health, disease and illness, and the experiences and
forms of knowledge to which they relate, are the subjects of this opening
chapter. In order to structure the discussion, the chapter is organized
round four themes:
• The medical model of health and illness
• Lay concepts of health
• Health as attribute and health as relation
• Health and illness – physical and mental
1
What is Health?
These themes comprise substantive topics in their own right, but the discussion
of them will also act as a lead into the subsequent chapters of
the book. Many of the wider dimensions of health and illness – including
their cultural and political features – will figure throughout the book.
Examples of the most recent controversies in health are dealt with particularly
in the latter stages. In this opening chapter, however, we need
to begin with the basics and establish a conceptual map of the field.
The Medical Model of Health and Illness
On the surface it may seem somewhat perverse to begin a book on the
sociology of health and illness by considering the medical model.
However, given the importance, not to say dominance of medical science
and medical practice in modern times, understanding the medical
approach to health is a necessary starting point. Much of what contemporary
populations think about health and illness, and much of the focus
of research – including sociological research – is strongly influenced by
the prevailing medical model. In public debate, the medical approach
remains central. It is therefore with this topic that we begin.
It is often said that the medical model of health is a negative one: that
is, that health is essentially the absence of disease. Despite bold attempts
by bodies such as the World Health Organisation (WHO) to argue for
a definition of health as ‘a state of complete physical, mental and social
well-being, and not merely the absence of disease or infirmity’
(<www.who.int/about/overview/en>), most medically related thought
remains concerned with disease and illness. This is hardly surprising,
given the fact that people turn to medicine in times of trouble, not when
they are feeling well. It has also been found that promotion of positive
health, whether by doctors or ‘health promoters’, competes with other
valued goals, for individuals and for societies as a whole. Matters become
even more complicated when it is realized that the presence of ‘disease
or infirmity’ does not, in any event, mean that people always regard
themselves as unhealthy – as we shall see below. The phrase ‘complete
well-being’ remains as elusive as it is positive, and health, illness and
medicine are related in complex ways. The medical model of health,
though often charged with ‘reductionism’, at least has the attraction of
cutting through some of these knots.
As historians such as the late Roy Porter (2002a) have pointed out,
the medical model, as we now know it, took on its main characteristics
in the eighteenth and nineteenth centuries. Prior to this date most medicine
in Western countries was committed to observation and the exhaustive
classification of symptoms. Although this attachment to observation
2 WHAT IS HEALTH?
entailed a rejection of existing authorities (represented especially in
Galen’s writings) and was linked to a reformist view of science and
society, developments were not straightforward. For many physicians in
the seventeenth and eighteenth centuries, emerging views concerning the
nature of disease were anathema. Physiology in France and chemistry in
Germany were bringing the laboratory sciences to bear on human health
and disease, and many thought this undermined the doctor’s traditional
role at the patient’s bedside. However, during the nineteenth century, the
development of bacteriology and pathological anatomy marked a major
change in both thought and practice.
Instead of the seemingly endless classification of symptoms, the idea
of ‘specific aetiology’ took hold, tracing the pathways of disease from
underlying causes to pathology in human tissue or organ, and then to
the manifestation of symptoms. Thus, specific causes were linked to
specific diseases in particular organs, and the task of the physician was
to trace the presenting symptoms back to their underlying origins. This
model of disease flourished in the late nineteenth and early twentieth
centuries, and was particularly associated with the discovery of the
mechanisms that lay behind the infections – the so-called germ theory of
disease. Although not all physicians, even then, as Porter (2002a) makes
clear, accepted the idea of disease specificity, preferring to see sickness
occurring when ‘normal functions went awry’ (p. 78), the pathologically
based and causally specific medical model became increasingly dominant.
In order to illustrate what is meant here, let us take an example:
the case of tuberculosis, an infectious disease responsible for a quarter
of all deaths in the second half of the nineteenth century and the most
important threat to health at that time (Webster 1994). In the medical
model of disease, tuberculosis is defined as a disease of bodily organs
(usually the lungs, but sometimes other sites such as the spine) following
exposure to the tubercle bacillus. This exposure leads to pathological
changes in the body’s systems, and can be observed at x-ray as
damage to the surface of the lungs, in the case of respiratory tuberculosis.
The bacillus can be identified through culturing blood or sputum.
The development of the illness involves symptoms such as coughing,
haemoptysis (coughing up blood), weight loss and fever. In this model
the underlying cause of the illness is the bacillus, and its elimination from
the body (through anti-tubercular drugs) is aimed to restore the body
to health. In 1944, streptomycin was found to be active against the
tubercle bacillus.
The main point of this model of disease is that it attempts to uncover
underlying pathological processes and their particular effects. The
problem with earlier, symptom-oriented approaches to health was that
no such sequences of events could be established, and treatment could
WHAT IS HEALTH? 3
only be symptomatic. In the case of tuberculosis, the symptoms described
above are also found in other diseases, and this problem of linking symptoms
to specific underlying mechanisms frustrated medical development.
Fever, for example, is common to many infectious disorders. Once the
specific aetiology approach was accepted, such symptomatic approaches
were relegated to the margins of medicine. Although observation and the
treatment of symptoms were established practices in early modern medicine,
and have remained important to physicians ever since, it was often
difficult to distinguish such approaches from a wide variety of unorthodox
practices. Today, these are often referred to as forms of ‘complementary
medicine’ – herbalism and homeopathy, for example – that treat
symptoms ‘holistically’ – but do not rest on the idea of underlying, specific
pathological disease mechanisms.
The medical historian Christopher Lawrence has argued that by 1920
in Britain, and in other developed countries such as the USA, the medical
model, as outlined briefly above, had come to dominate medical thought
and practice and, increasingly, society’s attitude to health as a whole
(Lawrence 1995). The medical model was essentially individualistic in
orientation and, unlike earlier approaches, paid less attention to the
patient’s social situation or the wider environment. This narrowing of
focus (towards the internal workings of the body, and then to cellular
and sub-cellular levels), led to many gains in understanding and treatment,
especially after 1941, when penicillin was introduced, and the era
of antibiotics began. But it was also accompanied by the development of
what Lawrence calls a ‘bounded’ medical profession, that could pronounce
widely on health matters and could act with increasing power
and autonomy. Doctors now claimed exclusive jurisdiction over health
and illness, with the warrant of the medical model of disease as their
support.
This situation meant that modern citizens were increasingly encouraged
to see their health as an individual matter, and their health problems
as in need of the attention of a doctor. It is this which Foucault
(1973) saw as constituting the ‘medical gaze’ which focused on the individual
and on processes going on inside the body – its ‘volumes and
spaces’. Wider influences on health, such as circumstances at work or in
the domestic sphere, were of less interest to the modern doctor. This
‘gaze’ (extended in due course to health-related behaviours) underpinned
the development of the modern ‘doctor–patient’ relationship, in which
all authority over health matters was seen to reside in the doctors’ expertise
and skill, especially as shown in diagnosis. This meant that the
patient’s view of illness and alternative approaches to health were
excluded from serious consideration. Indeed, the patient’s view was seen
as contaminating the diagnostic process, and it was better if the patient
4 WHAT IS HEALTH?
occupied only a passive role. It is for this reason that the ‘medical model’
of disease has been regarded critically in many sociological accounts. The
power of the medical model and the power of the medical profession
have been seen to serve the interests of ‘medical dominance’ rather than
patients’ needs (Freidson 1970/1988, 2001) and to direct attention away
from the wider determinants of health.
However, before we proceed, two caveats need to be entered. Whilst
medicine in the last 20 years has continued to focus on processes in the
individual body, such as the chemistry of the brain or the role of genes
in relation to specific diseases, the current context is clearly different
from that which existed at the beginning of the twentieth century. Today,
in countries such as the UK and the USA, infectious diseases are of far
less importance as threats to human health. Though HIV/AIDS has
become one of the most serious infectious diseases in history, its major
impact is being felt in developing countries, especially in sub-Saharan
Africa, and those of the former Soviet Union. In the West, notwithstanding
the importance of infections when they do occur, the major
health problems today are the so-called degenerative diseases associated
with later life – conditions such as heart disease and cancer, and disabling
illnesses such as arthritis and stroke. This has been referred to as the
‘health transition’ (Gray 2001: 127).
The medical model, today, therefore, is as likely to emphasize the
complex or unknown aetiology of a disease as it is to discover its specific
‘cause’. Many diseases can properly be recognized only by referring
to a set of criteria (often arrived at by international groups of doctors)
rather than identifying one underlying factor; diagnosis is often probabilistic
rather than definitive. Treatment, in turn, may often be ‘palliative’,
that is, trying to reduce the impact of symptoms, or contain the
disease, rather than hoping to cure it completely. In addition, many
doctors today work within multidisciplinary teams, rather than as isolated
practitioners. They recognize (as the more thoughtful doctor has
always done) the wider influences on health and the impact of disease
on patients’ lives. Indeed, the rhetoric currently surrounding ‘patient
partnership’ and ‘shared decision making’, to be found in many developed
health care systems, need not be treated entirely cynically. Many
health care professionals are attempting to reshape health care to meet
the new needs and demands of their patients. These changes need to be
borne in mind as we look at the issues of medical power and the continuing
influence of medical science later in this book.
Second, the individualistic approach to disease is not the only
approach to health to be found in a more broadly defined medical model,
though it may be the dominant one. Most developed societies have also
had a long tradition of public health, focusing not on the individual but
WHAT IS HEALTH? 5
on the health of populations. Here, the diagnosis and treatment of individuals
is less important than measures of health for whole groups and
societies, however much these rely on medical scientific explanations of
disease and illness. The most important of such measures are rates of
mortality, morbidity and disability, data on which are collected and
studied by the scientific arm of public health, epidemiology. Their regularity
among and between groups of people is the focus of enquiry. As
one leading UK epidemiologist has put it, epidemiology
may be contrasted with the clinical observation of patients or the controlled
experiment in the laboratory [as] the study of the health and
disease of populations and groups in relation to their environment and
ways of living . . . and is being applied to a variety of health services
as well as health. (Morris 1975: 3)
Public health research, especially during the period dominated by the
infections, was preoccupied with mortality data, especially the how,
when and why of early death. For example, one of the most important
measures of population health is the infant mortality rate (IMR), which
calculates the number of deaths in the first year of life per thousand live
births. Today the IMR for the UK is 5.5 and for the USA, is 6.8. However,
the IMR for India is 63, and for Mali in West Africa, 121. Such statistics
have been, and still are, an indication of the different life circumstances
and health of the populations in these countries, in that high
infant deaths are associated with poor maternal health and poor social
circumstances. However, in Western countries, mortality statistics have
become less sensitive indicators of population health as social conditions
have improved (for mothers and other groups) and as the rates at all
ages have continued to fall. None the less, as we shall see in chapter 2,
much epidemiological research, and medical sociology work related to
it, still rely on mortality data.
In recent years, though, public health and medical sociology have been
concerned to develop more sensitive measures of health, still broadly
within what one might call a ‘socio-medical’ model of health, but dealing
with morbidity and disability (Bury 1997: 116). In such an approach,
morbidity refers to measures of illness, and disability to measures of
activity restriction and functional limitation, together with measures of
quality of life. The important point to grasp at this stage is that the
medical model contains a number of different strands of thought about
human health, and different approaches to its study. This holds true, also,
for the medical profession, which includes physicians, surgeons and
general practitioners, together with public health doctors and epidemiologists.
Whilst most medical practice has been individualistic in orientation,
some forms of medicine (especially that focusing on human
6 WHAT IS HEALTH?
populations) have adopted a larger vision, and this often overlaps with
sociological concerns. Medicine, like health, covers a wide range of phenomena
and human activity, and this needs to be remembered when
general statements about the ‘medical model’ or ‘the medical profession’
are made.
Lay Concepts of Health
If the above account of the growing dominance of the medical model is
reasonably accurate, it might be expected that lay concepts of health in
modern societies would be strongly influenced by it in modern times.
Explanations for events such as illness are rarely couched, for example,
in religious terms, at least not by the majority of lay people in countries
such as the UK and the USA, though such ideas may be prevalent in particular
communities. Medical information is disseminated and available
in numerous ways today, especially through television, the Internet and
other media. If the development of an individualistic medical model has
shaped lay understanding and experience of health, then modern cultures
have been equally conducive to its widespread acceptance. It would be
surprising, under these circumstances, to find an entirely separate system
of ‘folk beliefs’ about illness, shaped by a non-medical culture.
At the same time, enough has already been said to indicate that health,
illness and medicine refer to a wide range of events and experiences, and
ideas about these are bound to contain tensions and contradictions, as
well as ambivalence about the role of medical treatments in dealing with
them (Williams and Calnan 1996: 17). Sociological research on lay concepts
of health has provided important insights into the complexity and
sophistication of views about such matters. Whilst this work has shown
the widespread absorption of medical messages about health, it has also
shown how this is translated and reconciled with other areas of life, and
assessed against alternative sources of information. Modern ideas about
health and illness can also draw on earlier notions, such as the need for
‘balance’ in sustaining well-being.
In the first place it needs to be recognized that health may be an overriding
concern to health care professionals and researchers, including
medical sociologists, but not for lay people in everyday life. Health, for
many, and for most of the time, is part of the ‘natural attitude’ to life,
in which taken-for-granted meanings are an essential background and
are unconsidered for much of the time. In his study of risk behaviour
and HIV, Bloor (1995: 26), for example, drawing on the writings of
Alfred Schutz, distinguished between ‘the world of routine activities’ and
‘a world of considered alternatives and calculative action’ in interpreting
how health risks were perceived by his respondents. Bloor’s study
WHAT IS HEALTH? 7
reinforces the view that daily life presupposes health, unless it is threatened
by events or information that draw the layperson into considering
alternatives. Health risks vie with the routine nature of daily life, with
its own pressures and pleasures, constraints and potentialities. As we
shall see below, only a minority of people are forced, or choose, to
abandon an assumption of health as a given. Those concerned with
health promotion (as opposed to the treatment of illness) who wish to
encourage lay people to become more health-conscious have to face this
issue in doing so. Health is not necessarily a pressing and overriding
value, consciously considered on a daily basis. Information on health
risks is actively interpreted within specific social contexts (Alaszweski
and Horlick-Jones 2003).
In addition to this, lay thinking about the causes or origins of good
and ill health has been found to be characterized by complex considerations.
Even if health is often taken for granted, and only missed when
it is felt to be compromised, this does not mean that lay people lack clear
ideas about the relationship between health and illness. In one of the earliest
and most influential studies of lay concepts of health, Herzlich
(1973) showed how, among a sample of 80 middle-class French respondents
(mostly from Paris) health was linked to the connections between
individuals and ‘the way of life’. Health beliefs, or the ‘representations
of health’ as Herzlich called them, located the source of illness in the
character of urban living, with its tendency to create stress, fatigue and
nervous tension. This, it was felt, could ‘facilitate’ or ‘release’ forces that
could aid the development of illness. But such forces could also ‘generate’
illness – that is, be more pathological in their own right – and not
just exacerbate existing problems, for example, by making an infection
worse.
Positive health, on the other hand, was seen to be inherent in the individual.
The balance or ‘equilibrium’ between the healthy individual and
illness could be upset by a number of features of the environment. Cancer
was linked to allergies, and to the nervous strain of city life and the polluted
atmosphere found there. Mental illness was linked to the ‘restlessness’
of modern living, and heart disease to the ‘many worries which
make people live in a certain state of anxiety’ (Herzlich 1973: 22). Whilst
the respondents in this study recognized that individual attributes might
contribute to poor health, these attributes were never seen as both necessary
and sufficient. The individual’s ‘nature’, heredity, temperament or
predisposition might make the individual vulnerable, but the ‘way of life’
remained crucial to the development of poor health.
If Herzlich’s work set out to provide a framework for understanding
the links between way of life and the individual in lay concepts of health,
subsequent work has explored their variation across different age and
8 WHAT IS HEALTH?
social groups. In a study which builds conceptually on Herzlich, but
draws on a large national study of health and lifestyles in the UK, Blaxter
(1990) has provided a detailed picture of some of these variations. This
study also shows that health is not a single or unitary concept, but one
that has a number of dimensions as applied to different areas of life and
lifestyles (see also Blaxter 2003, 2004).
Blaxter’s (1990) discussion of lay beliefs is drawn from responses to
open-ended questions about health put to 9,000 respondents in England,
Wales and Scotland. Overall, these responses show that for lay people
‘health can be defined negatively, as the absence of illness, functionally
as the ability to cope with everyday activities, or positively as fitness and
well-being’ (p. 14). However, there are two important additions to this
general picture. The first is that health has a moral dimension, reflecting
not only the adoption or maintenance of a healthy lifestyle, but also how
people respond to illness and deal with its aftermath. Illness runs the risk
of devaluing a person’s identity, either because of its causation (e.g.
smoking, sexual contact, failure to ‘keep well’) or because of inappropriate
behaviour in the face of symptoms. Moral dimensions of health
have been found in a number of other studies, such as Conrad’s (1994)
study of students in the USA and G. Williams’s (1984) study of middleaged
and older people with arthritis in England. From this viewpoint
illness is not simply a deviation from biological norms, as in the medical
model, but a significant departure from social norms.
Second, Blaxter shows that health, illness and disease are not always
mutually exclusive in lay thought. Respondents in her study often
reported that they saw themselves as healthy despite having serious conditions
such as diabetes. There is clearly a strong motivation towards
feeling and being seen to be healthy, if at all possible. This issue becomes
particularly salient when the question of disability is considered, given
the complex relationship between health and a range of different disabling
conditions. For individuals with stable disabilities, or conditions
that are not accompanied by generalized illness or ‘malaise’, being
healthy may be redefined to incorporate how the person feels now, not
in relation to a general norm. Adaptation to illness or disability alters
the baseline from which the individual judges the nature of health and
its implications. As we shall see below, however, and in more detail in
chapter 4, the relationship between disability and health has become
highly controversial.
One of the main strengths of Blaxter’s study is that it shows the importance
of gender and age to such definitions of health. Blaxter argues that
health in much lay thinking can be seen to constitute a form of ‘reserve
stock’, to be invested in by adopting healthy behaviours, or diminished
by self-neglect or unhealthy behaviours (Blaxter 1990: 16). The ‘health
WHAT IS HEALTH? 9
capital’ we are born with can be seen as a function of heredity and as
being shaped by development in the early years of life. But people in later
life may feel that their ‘stock’ is diminishing or running down. Problems
with mobility, eyesight and hearing are obvious examples. In Blaxter’s
study older people did, indeed, report more negative views of their
health, with men under the age of 40 more likely to emphasize a positive
notion of ‘fitness’. Health as functioning – being able to carry out
self-care and other routine tasks – is likely to increase in importance with
age, and likewise is largely taken for granted among the young. For
young women, however, Blaxter’s study underlined the importance of
social relationships, as well as being patient with children and ‘coping
with the family’ (Blaxter 1990: 27).
In Blaxter’s study, then, the nuanced and multidimensional character
of lay health beliefs is underlined. This is of particular note, especially
in a period when health risks appear to be multiplying. For example,
fears have been expressed that the ‘new genetics’ will overwhelm modern
populations with burdensome information about potential health risks
and the need to make choices about an ever wider range of medical and
health-promoting interventions (including screening programmes). The
incorporation of an increasing number of human and social problems
into the medical and genetic orbit has led sociologists to analyse the
various forces, concerns and dilemmas involved (Conrad 2000). Even,
here, though, empirical research has found that lay people are able to
absorb or deal with even the most technical and complex information in
creative and practical ways. A brief example to conclude this section of
the chapter can serve to illustrate the point.
As part of an ongoing programme of research at Cardiff University,
Parsons and Atkinson (1992) reported on the knowledge and beliefs of
22 mothers and 32 daughters who had a known risk of carrying the gene
responsible for Duchenne muscular dystrophy, a disease that leads,
slowly, to a progressive degeneration of muscular tissue. It is inherited
through a recessive, sex-linked gene, so that only boys are affected, and
only women can pass it on. There is no effective treatment for the disease,
and the outlook for many affected individuals, in the medium term, is
poor. It might be expected that under these circumstances reproductive
decisions on the part of the women in the study would be likely to be
highly problematic. Each woman in the study had gone through several
assessments and tests, resulting, finally, in two sets of risk figures, one
for her carrier status and one for her risk of passing on the gene to any
offspring. In fact, Parsons and Atkinson found considerable confusion
on the part of some women as to the nature of the statistics they had
been given. However, the point of the study was not to demonstrate the
10 WHAT IS HEALTH?
women’s ability to account for their carrier status, or otherwise, but to
explore how the knowledge they did have was incorporated into daily
life. Parsons and Atkinson found that the women had invariably translated
statistical risk into ‘descriptive categories that had become routine
recipes for their reproductive behaviour’, so that specific figures could be
seen, for example, as putting them at high or low risk of transmission
(Parsons and Atkinson 1992: 441). Far from being disempowered by
expert knowledge, the women were able to use these descriptive statements
to inform action, in ways that the medical information could not.
Probabilistic knowledge derived from genetics was turned into more
certain guidelines that could deal with both decision making and social
relationships. For much of the time the women were able to relegate their
carrier status to a ‘low zone of relevance’. In this study health beliefs
were shown not only as sophisticated but also as practical, being fashioned
and refashioned as contexts and experiences changed. As we saw
earlier, health beliefs are integrated, where possible, into the routine
actions that constitute everyday life.
This is not to say that all lay health beliefs are true or unproblematic.
While medical sociology has made an important contribution to understanding
the rationality, relevance and socially contextualized nature of
lay health beliefs, it is important not to overstate the argument. Whilst
individuals have unique insights into their own situations, these cannot
be substituted for expert knowledge in all and every circumstance (Prior
2003). The economist Amartya Sen (2002) has shown, for example, that
when a comparative perspective of lay views is adopted, anomalies
quickly appear. Quoting data from India and the USA, he shows that the
higher the level of education in a population, the higher the level of
reported illness. This stands in contrast to more ‘objective’ measures,
such as mortality rates and life expectancy, which, as indicated earlier in
this chapter, are much more favourable in the USA than in a country
such as India. We should not conclude from their stated beliefs or behaviours
that people in the USA are less healthy than people in India. Rather,
we should see lay beliefs and behaviour, as well as the medical model,
as components of a dialectic, interacting in complex ways, and mediated
by different cultural settings.
Health as Attribute and Health as Relation
The previous two sections have explored, in outline, the medical model
and lay beliefs about health. One of the ways we can think sociologically
about the tension between the two is to consider health in terms of
WHAT IS HEALTH? 11
attribute and relation. The relationship between these two approaches
also provides us with a framework with which to approach some of the
most puzzling features of contemporary health phenomena.
If we take the idea of attribute first, much medical knowledge, and
considerable areas of lay belief influenced by it, make the assumption
that disease or illness is a property or attribute of the individual. Disease
from this viewpoint is an ‘it’ which the person has or harbours. In early
modern medicine it was often felt that scientific investigation ran the risk
of ‘reifying’ disease – that is, of creating a ‘thing’ separate from the individual
patient, where only observed symptoms could properly be identified.
Humoral medicine treated disease and its symptomatology as one
and the same. With the ascendancy of the ‘pathological anatomy’ perspective,
‘reified’ disease became increasingly dominant. In this new view,
disease was seen as a separate entity, both from the attempts to conceptualize
it or deal with it, and from the symptoms that might or might
not be related to it. Diseases such as tuberculosis, and bodily organs such
as lungs, exist, in this realist view, whether we name them or not, or
whether we live in a culture or a period of history which has a different
understanding. Moreover, many diseases exist without symptoms, especially
in their early stages – in some forms of heart disease and cancer,
for example. And the plethora of observable symptoms often do not map
on to disease in a one-to-one manner. The existence of cultures (or histories)
that do not conceptualize disease as an independent property of
the body does not mean that people do not have diseases or organs such
as lungs, hearts or livers (Craib 1995). Though diseases may be caused
by outside agents (bacteria, viruses), their essential character reside in
the human body, as an attribute of its physical make-up.
A relational view of health, by contrast, does not focus on the biological
determinants at work in the individual’s body. Rather, it points
to the social or psycho-social forces that influence the pattern and expression
of illness. This can be conceptualized in two ways: either in terms
of the ‘social creation’ of illness patterns through inequalities or environmental
factors, or in terms of the ‘social production’ of illness in individuals
through the contingencies and negotiations that surround its
identification, naming and treatment. This latter approach is especially
relevant to forms of chronic illness (Gerhardt 1989). Here, the process
of recognizing or naming a disease, by medical staff or lay people,
involves a range of factors, including the severity of symptoms, the age
and tolerance level of the sufferer, the social circumstances of the individual
(work or family difficulties, for example), and the interactions
between the person and the health care system. Many chronic conditions
are difficult to separate from the normal, again, especially in their early
stages, and there may not be a key hallmark, comparable with a bac-
12 WHAT IS HEALTH?
terium or virus, that can act as a definitive marker for the disease. In this
sense the disease or illness may be ‘negotiated’ before a definite name or
plan of action is agreed upon.
At this point, it may be thought that an attributional view of health
is largely the province of medicine and the medical model of health, and
a relational view that of lay people or, indeed, of the sociologist. In many
situations this may well be the case, but again the idea of dialectic is
important. Take the case of a disease such as osteoarthritis, a common
disorder of later life, involving progressive deterioration in the joints of
the body, especially the hips. As the disease is associated with age, many
people tend to discount the aches and pains which accompany it as features
of growing older, and treat them as more or less normal. Or, at
least, it has been found that people attempt to do so (Sanders et al. 2002).
Thus, reporting of such symptoms to the doctor is likely to be highly
variable. At the same time, the fit between symptoms and degree of
disease progression is often difficult for doctors to judge. Patients with
low levels of pain may have badly affected joints, and those in considerable
pain may not show signs of major physical changes (for example,
at x-ray). How the severity of the disease is judged, and whether or when
to intervene (for example, by surgical replacement of a hip), is, in part
at least, a matter for negotiation. It may be contingent on a host of
factors, not least the presence of a waiting list for surgery.
In this respect the medical view of disease cannot easily operate within
an entirely attributional perspective. Returning to our earlier point, and
as Healy (1999: 12) has pointed out, the ‘specific disease model’ of the
late nineteenth century overcame earlier confusions created by a form of
medicine which relied on a combination of theory and observation.
Healy cites the case of diphtheria in this period, which was often confused
with other throat problems, and only resolved when a specific diphtheria
organism was isolated. To repeat, the new medical model
emphasized that specific causes gave rise to specific diseases. Whilst this
may still hold true for some diseases today, the rise in importance of
degenerative conditions requires that medical knowledge and medical
practice often adopt a ‘multi-factorial’ model of illness, wherein physical,
psychological and social processes are recognized as playing an
important part. Even where genetic knowledge is giving renewed impetus
to the specific cause approach, it is recognized that genes may express
themselves in different ways in different individuals and within different
environments.
By the same token, a relational view of health is not always characteristic
of lay views. An attributional view of disease has, in recent years,
become highly attractive among some lay people, especially in connection
with problematic and contentious disorders. The ‘way of life’ may
WHAT IS HEALTH? 13
not always be the main emphasis in lay thinking about disease causation.
Conditions such as Attention Deficit Hyperactivity Disorder
(ADHD), Myalgic Encephalomyelitis (ME) or Chronic Fatigue Syndrome
(CFS), and Gulf War Syndrome are among the best publicized in this
regard. ME/CFS is held by many sufferers to be the result of a viral
illness, and not, as many doctors think, the outcome of psychological
problems including depression. The paradox lies in the fact that it is
patients, and not doctors, who are claiming that the illness results from
an underlying biological attribute, and it is doctors who are warning
against the ‘medicalization’ of ‘non-diseases’, fuelled by genetics on the
one hand and an expansionist pharmaceutical industry on the other
(Moynihan and Smith 2002). Claims made about the ‘objective’ or ‘real’
nature or causes of a disorder do not themselves, of course, mean that
they are true.
Nevertheless, the attraction for many lay people of regarding a condition
such as ME/CFS as a biological attribute seems unstoppable. The
UK organization Action for ME states, for example, that the disorder is
a ‘potentially chronic and disabling neurological disorder, which causes
profound exhaustion, muscle pain and cognitive problems such as
memory loss and concentration . . . it is estimated that around two thirds
of all cases are preceded by a viral infection of some kind’ (Action for
ME, <www.afme.org.uk>). Activists in areas such as this can become
hostile to arguments, especially from medical sources that fail to share
such an approach. To repeat, ME/CFS is only one among a number of
health problems which express a complex relationship between attributional
and relational issues, that do not necessarily follow the disease =
medical, illness = lay distinction.
If we bring disability into the picture again, these problems are thrown
into sharp relief. As G. Williams (2000) has noted, for most doctors and
lay people the idea of disability has been as a ‘property’ of the individual.
Impairments resulting from disease or trauma, that alter the structure
or functioning of the body, become disabling. By this is meant that
the affected individual has difficulty or is unable to perform the usual
tasks that a non-impaired person would be able to carry out, such as
self-care or mobility. The causal chain of disease/trauma Æ impairment
Æ disability reproduces the essential characteristics of the medical model
described earlier. This attributional view of disability has dominated not
only medical thought, but also lay understanding. Indeed, without it, it
would be difficult to make any assessment of the degree of disability or
to allocate resources (for example, designated parking places or disability
allowances) with any degree of fairness. If it is not possible to distinguish
between the able-bodied and the disabled in attributional terms,
then such issues become almost impossible to resolve.
14 WHAT IS HEALTH?
In recent years, however, radical voices in the disability movement
have sought to separate disease, impairment and the body, on the one
hand, from disability, on the other. In this view disability is wholly relational,
in that it is seen to be a product of social oppression and discrimination
(Oliver 1996: 35). The idea of disability being a property or
attribute of the individual has become anathema to some, and its essentially
relational character a test of radical disability credentials. Considerable
argument has ensued about the nature of disability between these
two poles, both within the disability movement and between disability
activists and medical sociologists (Bury 1996; Shakespeare 1999).
G. Williams notes that sociologists such as Irving Zola (who was himself
disabled) have argued that moving too far in either the relational or the
attributional direction oversimplifies the complex problems involved.
Instead, Zola favoured a formulation widely used in the USA: namely,
that of referring to ‘people with disabilities’ (G. Williams 2000: 139;
Zola 1993), recognizing both the bodily and the social dimensions at
work.
These issues will be returned to in greater detail in chapter 4 of this
book. The main point to note here is that in the field of health and illness,
and in areas such as psychosomatic disorders or disability, a tension
between attributional and relational aspects is inevitably present. A critical
sociological view of health has at its centre the dialectic of physical
and social dimensions. This is not the same, however, as arguing that
health and illness are merely ‘social constructs’, in the sense that they
depend only on shifting social contexts and different interests at work.
The difficulties with a sociological view that gives no place to the biological
and ‘embodied’ character of health is that it leaves the body and
its make-up (especially in the current period, its genetic make-up) to
medical scrutiny alone. To argue that health has a social dimension is
not to say that it has no independent or physical basis; nor is it to argue
that medical knowledge is little more than the exercise of unwarranted
power over the layperson. Some disorders are controversial and difficult
to define, others are not. In some circumstances physical symptoms inexorably
overwhelm the individual’s body, in others they are recognized
only through a more negotiated process. Indeed, these different aspects
of experience will often unfold in varying ways in the course of a particular
illness. How perceptions, experience and action work their way
through in specific disorders is a matter for empirical analysis. This book
will suggest that a dynamic view of health is needed, one in which
changes over time (across the individual lifecourse, and in different societies
at different historical periods) become the focus of analysis. In such
a view, attribute and relation are necessary concepts for a full understanding
of health.
WHAT IS HEALTH? 15
Health and Illness – Physical and Mental
Up to this point the discussion has been largely concerned with physical
health and physical illness or disability. Indeed, much of this short book
will necessarily be confined to physical health and illness. None the less,
this introductory discussion cannot properly conclude without considering,
if only briefly, the difficult issues presented by mental health.
In recent years, as Busfield (2000) has pointed out in a useful review,
developments in genetics, neuroscience and pharmacology have tended
to reinforce a perspective of mental health as being determined by bodily
processes – what here has been called an attributional view. The idea
that mental health is a product of the individual’s biological make-up
has proved attractive to lay people as well to those in medicine in many
different periods of history. A materialist – not to say mechanical – view
of the body, and especially the brain with its structures, linkages and
chemistry, has dominated medical and psychiatric thought since early
modern times, following the rejection of ‘demonic’ and religious-based
explanations of mental disturbance. Developments in psychology, and
the influence of thinking such as Freud’s on the role of early development
and fantasy in human affairs, have not displaced the desire among
most psychiatrists to remain in the medical mainstream. Not surprisingly,
therefore, a medical model of mental health has continued to be influential
in lay cultures. The apparent neutrality of the medical model also
has its attractions. As with other forms of illness, to be told that a mental
disorder is the result of an organic disturbance provides a way of resisting
claims that it may result from a failure of character or from a weak
will.
Indeed, one of the main difficulties with mental illness is that it often
involves changes in behaviour which attract moral opprobrium. Strange,
difficult or threatening behaviour, as Fabrega and Manning (1973) and
Goffman (1971) argued over 30 years ago, reflect on the selfhood of the
putative patient and create interactional difficulties. In physical ill health
it is often possible to distance oneself from the disorder in question by
appealing to independent influences such as germs or viruses, or to other
non-motivational factors. As was shown above, however, concepts of
health and illness often carry moral connotations; even a simple infection
such as influenza may be thought to be the result of self-neglect, and
more serious illnesses are often linked to poor lifestyle choices such as
smoking or over-indulgence in food or alcohol. Nevertheless, mental
health is particularly prone to negative judgements, because the very definition
of the problem is linked to the person’s self or behaviour. For an
individual to say that they cannot work because of an infection or other
16 WHAT IS HEALTH?
more serious physical illness is, even today, quite different from disclosing
the presence, for example, of depression or psychosis. The latter illnesses
almost always raise questions about the individual and their
personality (including the risk of dangerous or disturbing behaviour),
and this contrasts strongly with disclosures of physical illness. It is no
wonder, then, that an ‘attributional’ view, which locates mental illness
in the person’s biological make-up, has proved attractive to professional
and lay audiences alike, even though this may only reduce rather than
eliminate negative reactions.
By the same token, approaching mental health in relational terms –
in terms of interpersonal and social processes – does not always find
favour in professional or lay circles. Studies of the family dynamics of
mental illness in the 1960s appeared only to end up ‘blaming the victim’
– in this case the families caring for seriously mentally ill individuals.
Yet, psycho-social theories and the social circumstances of many of those
suffering from mental health problems provide a continuing basis for
sociological research and policy. As Busfield (2000) makes clear, sociology
has had, and continues to have, much to contribute to the understanding
of mental health by examining its social dimensions. Following
the discussion in the last section, it is possible to distinguish the role of
the social in the ‘creation’ or causation of mental illness, from its ‘social
production’ – that is, the expression and definition of the illness and the
way it unfolds in social interaction.
As Busfield states, there is a long history of social and epidemiological
research on the creation or occurrence of mental illness. Whilst this
has sometimes been criticized by sociologists for taking the medical definition
of illness (or ‘mental disease’) as given, much of the work has
challenged the individualistic orientation of psychiatric thought. In early
pioneering studies in the USA, Faris and Dunham (1965 [1939]) and
Hollingshead and Redlich (1958) attempted to show that mental disorder
was not a random event, dependent solely on the individual’s biological
characteristics, but was patterned by social circumstances
(including poverty) and social class. In this way, mental health has been
located as an aspect of health inequalities (Rogers and Pilgrim 2003),
showing that its occurrence is significantly determined by social factors.
However, debates concerning the role of factors such as ethnicity and
racism in serious mental illnesses such as schizophrenia (Littlewood and
Lipsedge 1997; Kelleher and Hillier 1996) vie with evidence indicating
their universality across social groups. This indicates that social influences
on their causation are open to doubt (Hafner and an der Heiden
1997) and require careful assessment.
One of the difficulties in explaining mental disorder is that much of
it is hidden. At any one time the number of people being treated is only
WHAT IS HEALTH? 17
a fraction of those living with undiagnosed illness in the community. If
the study of mental illness concentrates on those already in contact with
the services, little can be said about its origins, unless a clear account
can be given of the selection process that has led some to receive treatment
and some not. Moreover, social conditions may change between
the onset of a disorder and making contact with services, acting as a
further confounding factor. Although the US studies, mentioned above,
tried to estimate this effect, large-scale epidemiological studies in the
community are difficult and expensive to mount (and run the risk of creating
large estimates of illness which fuel the ‘medicalization’ of whole
communities, and provide new markets for the pharmaceutical companies).
In Britain, one of the best-known studies of mental disorder in the
community (in this case, depression) attempted to control for the possible
confounding factors involved by making rigorous assessments of the
circumstances surrounding the onset of illness among community-based
samples (Brown and Harris 1978). This study challenged prevailing definitions
of depression by showing that severe life events involving loss
and threat had a major impact on the onset and development of depression,
in the presence of vulnerability factors such as early loss of a
mother, low socio-economic status and the lack of a confiding relationship.
Subsequent work in this tradition has shown that neglect and abuse
in childhood also have a significant influence on the occurrence of adult
depression, indicating that genetic influences are unlikely to be a major
determining factor in this disorder (Bifulco and Moran 1998).
As far as the ‘social production’ or shaping of mental health is concerned,
a number of important studies, especially in the USA during the
1960s and 1970s, employed a deviancy perspective to try to explain the
medicalization of disturbing and distressing behaviours in terms of
illness. Perhaps the best-known study of this period is Scheff’s Being
Mentally Ill (1999 [1967]). Scheff’s argument, essentially, revolved round
two key concepts. The first of these is ‘residual deviance’, which, he
argued, helps explain the wide variety of disorders and conditions which
are held to make up mental illness. ‘Residual deviance’ is essentially
behaviour which is found to be unacceptable, but which is not categorized
in other ways, such as being regarded as criminal. This approach
to mental illness draws heavily on labelling theory, in that the behaviour
designated as mental illness is that which attracts the label. Behaviour
so labelled in one time or place might not be so labelled in another time
or place. Goffman (1963a) famously pointed to the example of praying.
Being on one’s knees in a praying posture is acceptable in a designated
religious building, but not on the street outside. The contexts and contingencies
surrounding particular problems help explain their labelling,
or otherwise. Homosexuality, once regarded as a mental disorder by psy-
18 WHAT IS HEALTH?
chiatry, is not regarded as such now, having been voted out of psychiatric
classifications by American and British psychiatrists in the 1970s.
In such ways mental illness can be produced, or not, depending on social
contingencies.
Second, Scheff argued that ‘societal reaction’ to residual deviance
helps explain the career of mental health patients. Once labelled, the individual
is likely to take on the characteristics of the label, thus confirming
the original social response. Like Goffman (1963b), Scheff saw that
identity could be powerfully influenced, and indeed spoiled, by one characteristic
of the individual being generalized to their whole self. The
stigma of mental illness, as a diagnosis, could have real effects, independently
of any underlying disorder. Institutional ‘warehousing’ of psychiatric
patients in large mental hospitals, which had come to dominate
the pattern of care during the twentieth century, seems to have served
only to reinforce this process. Though critics such as Gove (1974) argued
that negative societal reaction was the last, rather than the first, resort
of families and communities to disturbing behaviour, Scheff’s work,
along with other ‘anti-psychiatry’ arguments at the time, provided a
powerful challenge to social and professional attitudes towards mental
illness.
In recent years, the writings of Foucault (1967, 1973) have been used
to supplement and reinforce a critical view of psychiatry, medicine and
social control, in ‘producing’ mental illness. For Foucault, the control of
mental illness was expressed by the ‘great confinement’ in eighteenthand
nineteenth-century France, leading to the repression of ‘unreason’
and the policing of troublesome and threatening behaviour. Here the
state and the medical profession were seen as treating mentally ill people
as excluded from the world of reason, and consigning large numbers of
them to the degrading conditions of mental hospitals. However, as Porter
(2002b) has argued, such a picture is simplistic and over-generalized,
especially when applied to other countries such as the USA and UK,
where hospitalization of the mentally ill was on a relatively small scale
until the end of the nineteenth century. Porter also shows that a number
of vested interests (and safeguards) were at work in shaping responses
to mental illness, though he also sees that by the Second World War many
large hospitals had ‘degenerated into sites dominated by formal drills,
financial stringency, and drug routines’ (p. 120), with some 150,000
inmates being in such institutions in Britain in 1950. Their numbers had
dropped to some 30,000 by the 1980s (p. 211).
It is somewhat paradoxical, perhaps, that attempts to ‘de-institutionalize’
the mentally ill in the last 20 years have gone hand in hand with
a renewed emphasis on the biology and genetics of mental health, as
much as on its ‘relational’ character. One way in which this paradox is
WHAT IS HEALTH? 19
explicable is, of course, to be found in the widespread use of anti-psychotic,
anti-depressive and anxiolytic drugs. Though based on chemical
and neurological theories of mental illness, they have effectively ‘dampened
down’ symptoms and made patients relatively more manageable in
the community. The pharmacological revolution in psychiatry has been
married with policies to develop widespread forms of ‘community care’.
Whether this counts as a more effective way of treating the mentally ill
and helps to reduce its ‘production’ or has led to a more tolerant view
of mental health problems is a matter of judgement rather than hard evidence.
The ability of people in different social contexts to tolerate and
respond positively to a range of illness states is clearly contingent on
many factors, including the degree of disruption of social interaction they
involve and the level of tolerance of families, workmates and wider communities.
Nevertheless, mental health continues to present particular difficulties,
especially when people ‘translate disgust into the disgusting and
fears into the fearful’ (Porter 2002b: 62). The distinctions between social
responses to mental illness and physical illness raised here remain powerful
ones and need to be borne in mind in discussions about health.
Concluding Remark
Health can be seen as a multifaceted dimension of human life, and as a
‘reserve stock’ (Blaxter 2003, 2004) of vitality, fitness and strength
(whether psychological or physical or both) which individuals can draw
upon to pursue their goals and actions. From a sociological viewpoint
health can be seen as both ‘attribute’ and ‘relation’, simultaneously
involving biological and social factors. This suggests a dynamic view of
health and illness, changing across biographical and historical time. The
experience of health, both good and poor, is likely to be influenced by
the circumstances into which people are born and the contexts and
actions which prevail at different stages of life. Health and illness thus
take us to a crucial intersection of biography and history.