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- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Sprache: Englisch
What is health? What does health mean to people? How do we make sense of health and experience it?
There are no simple answers to these questions. Health is complex, subjective and varied. Drawing on theory, research and contemporary debates, Ruth Cross explores the nature of health in depth and challenges our thinking about it. Moving beyond taken-for-granted assumptions, she gives the meaning of ‘health’ its due attention, exploring everyday perspectives as well as ‘expert’ medical, academic and policy understandings and approaches. In doing so, the book brings together different knowledge and expertise on health, also considering the inextricable links between human and planetary health.
This book is important for all those working in the health field, or training to do so, seeking a broad understanding about health and all its complexity.
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Veröffentlichungsjahr: 2024
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Table of Contents
Cover
Title Page
Copyright Page
Detailed Contents
Dedication
Acknowledgements
Introduction
1 What is Health?
Introduction
The importance of health
Health: complex and contested
Definitions of health
The contribution of the World Health Organization
Health as a social construct
Health as a moral phenomenon
Lay perspectives and lived experience
Summary
Further reading
2 Dimensions of Health
Introduction
Physical health
Mental health
Spiritual health
Emotional health
Social health
Societal health
Holistic health
Summary
Further reading
Notes
3 Models of Health
Introduction
An introduction to models of health
Lalonde’s health field concept
The biomedical model of health
The social model of health
The biopsychosocial model of health
Application of the biopsychosocial model of health to mental health and illness
A working model of health
Indigenous models of health
Māori models of health (Aotearoa/New Zealand)
Indigenous communities in Canada
Summary
Further reading
Notes
4 Determinants of Health
Introduction
What are determinants of health?
Social determinants of health
Social class
Gender
Commercial determinants of health
Technology as a determinant of health
Dahlgren and Whitehead’s (1991) model of health determinants
The Commission on the Social Determinants of Health (CSDH) framework (Solar and Irwin, 2010)
Health inequality and inequity
Structure and agency
Tackling the social determinants of health
Summary
Further reading
5 Health as Well-being
Introduction
What is well-being?
Theories of well-being
Experiences of well-being
Measuring well-being
The Geneva Charter for Well-being
Quality of life
Summary
Further reading
Notes
6 Health as Happiness
Introduction
What is happiness?
Happiness and health
Determinants of happiness
Measuring happiness
Summary
Further reading
Notes
7 Creating Health
Introduction
Creating health
The theory of salutogenesis
Sense of coherence
Generalized resistance resources
Research on salutogenesis
Salutogenic approaches to health
Asset-based approaches to health
Summary
Further reading
8 Health and Our Planet
Introduction
Human and planetary health
Climate change
Extinction threat
Ecological health
The future of human health
Summary
Further reading
Final Thoughts
References
Index
End User License Agreement
List of Tables
Chapter 1
Table 1.1: Changing understandings of health in the West over time
Table 1.2: Svalastog et al.’s (2017) lay perspectives on health
Chapter 3
Table 3.1: Health field concept elements
Table 3.2: Three main aspects of individual social health
Table 3.3: Three Māori models of health
Chapter 4
Table 4.1: Application of the rainbow model to malaria
Table 4.2 Tackling the social determinants of health
List of Illustrations
Chapter 3
Figure 3.1: The health field concept
Figure 3.2: The medical model of health
Figure 3.3: The social model of health
Figure 3.4: The biopsychosocial model of health
Figure 3.5: A working model of health
Chapter 4
Figure 4.1: Dahlgren and Whitehead’s rainbow model of health determinants
Figure 4.2: Solar and Irwin’s model
Chapter 5
Figure 5.1: Labonté’s model of health
Chapter 8
Figure 8.1 Barton and Grant’s health map
Guide
Cover
Table of Contents
Begin Reading
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What is Health?
Ruth Cross
polity
Copyright Page
Copyright © Ruth Cross 2024
The right of Ruth Cross to be identified as Author of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
First published in 2024 by Polity Press
Polity Press
65 Bridge Street
Cambridge CB2 1UR, UK
Polity Press
111 River Street
Hoboken, NJ 07030, USA
All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.
ISBN-13: 978-1-5095-5648-9
ISBN-13: 978-1-5095-5649-6(pb)
A catalogue record for this book is available from the British Library.
Library of Congress Control Number: 2023950666
by Fakenham Prepress Solutions, Fakenham, Norfolk NR21 8NL
The publisher has used its best endeavours to ensure that the URLs for external websites referred to in this book are correct and active at the time of going to press. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate.
Every effort has been made to trace all copyright holders, but if any have been overlooked the publisher will be pleased to include any necessary credits in any subsequent reprint or edition.
For further information on Polity, visit our website: politybooks.com
Detailed Contents
Acknowledgements
Introduction
Chapter 1 What is Health?
Chapter aims
Introduction
The importance of health
Health: complex and contested
Definitions of health
The contribution of the World Health Organization
Health as a social construct
Health as a moral phenomenon
Lay perspectives and lived experience
Case Study 1: Young women, risk and health
Summary
Further reading
Chapter 2 Dimensions of Health
Chapter aims
Introduction
Physical health
Mental health
Spiritual health
Emotional health
Social health
Societal health
Holistic health
Case Study 2: Holistic approaches to sexual health
Summary
Further reading
Chapter 3 Models of Health
Chapter aims
Introduction
An introduction to models of health
Lalonde’s health field concept
The biomedical model of health
The social model of health
The biopsychosocial model of health
A working model of health
Indigenous models of health
Case Study 3: Models of health and disability
Summary
Further reading
Chapter 4 Determinants of Health
Chapter aims
Introduction
What are determinants of health?
Social determinants of health
Dahlgren and Whitehead’s (1991) model of health determinants
The Commission on the Social Determinants of Health (CSDH) framework
Health inequality and inequity
Structure and agency
Tackling the social determinants of health
Case Study 4: Fuel poverty, cold homes and health inequalities in the UK
Summary
Further reading
Chapter 5 Health as Well-being
Chapter aims
Introduction
What is well-being?
Theories of well-being
Experiences of well-being
Measuring well-being
The Geneva Charter for Well-being
Quality of life
Case Study 5: Hygge and fika – Scandinavian well-being practices
Summary
Further reading
Chapter 6 Health as Happiness
Chapter aims
Introduction
What is happiness?
Happiness and health
Determinants of happiness
Measuring happiness
Case Study 6: Social media, happiness and health
Summary
Further reading
Chapter 7 Creating Health
Chapter aims
Introduction
Creating health
The theory of salutogenesis
Research on salutogenesis
Salutogenic approaches to health
Asset-based approaches to health
Case Study 7: Asset-mapping in rural Ecuador
Summary
Further reading
Chapter 8 Health and Our Planet
Chapter aims
Introduction
Human and planetary health
Climate change
Extinction threat
Ecological health
The future of human health
Case Study 8: A One Health approach benefiting the health of people and gorillas in Uganda
Summary
Further reading
Final Thoughts
References
Index
Dedication
Dedicated to my nieces, nephews and goddaughters.
You bring me so much happiness, thank you. I hope you live healthy, happy lives – whatever that looks like to each of you.
Love you all, always and forever.
Acknowledgements
I would like to acknowledge the contribution of the following people and extend my sincere gratitude to them.
Polity Press for supporting the development of this book from start to finish, particularly Jonathan Skerrett for his instrumental advice throughout the process, and Karina Jákupsdóttir for her patience in working together to finalize the book cover.
The students I work with, from whom I learn something new every day.
The anonymous reviewers who took the time to read through draft chapters and provide valuable and constructive comments. Your contribution has made this a more rounded book. I hope I have done your insights justice.
MAC, thank you for everything.
Introduction
For those working in health, health promotion or any health-related field, understanding what health is (what it means to people) is crucial for implementing effective policy and practice. Often, however, the students I work with on the programmes I teach have a relatively narrow understanding of health. Their viewpoints then change significantly as they are exposed to, and engage with, different ideas and perspectives.
This book came into being because I wanted to write a more in-depth piece of work about what health is, having already written several introductory chapters on this subject in books on health studies, health promotion and public health. A few thousand words cannot do justice to the complexity of health. This book does not do full justice to it either, but it does provide greater scope to consider what health is in more detail and to better explore its complexities and nuances. As such it includes discussion about many aspects of the subject, including different definitions, perspectives, dimensions and models of health; experiences of health; and determinants of health. It also discusses health as happiness and as well-being, as well as considering what creates health. The final chapter focuses on planetary health. A range of disciplines are drawn upon throughout the book, taking in ideas from sociology, psychology and economics.
There are several key themes within the book. At the outset it is important to note that the book has been written from the perspective that health is (largely) socially constructed, although it is also recognized that there is a physical dimension to health experience. In addition, positivist and social constructionist notions of health interact and influence each other and cannot be easily disentangled. Research, evidence and lay and Indigenous perspectives from around the world are drawn upon throughout the book to bring the discussion to life and give context. Lay perspectives are particularly important from a social constructionist perspective, and they can help bring some of the theoretical discussion into sharper focus.
The scene for the rest of the book is set in Chapter 1, which considers the question ‘what is health?’, acknowledging at the outset that the subject is complex and contested. The chapter starts by outlining why it is necessary to think about health in detail and to consider what health is. It examines different definitions of health, including the World Health Organization’s classic definition. The chapter introduces different philosophies of health and ideas of what it means to be ‘healthy’, drawing attention to the complicated and debated nature of health and differing lived experiences. It explores the social construction of health and highlights the importance of lay perspectives. More critical debates are also introduced in this chapter, in particular those around health as a social construct and as a moral phenomenon.
Chapter 2 explores the nature of health as multidimensional. In this chapter several different dimensions of health will be considered, each in turn. At the outset it is acknowledged that this is a highly theoretical, conceptual approach to take, since each dimension is not entirely discrete and different dimensions of health will overlap, intersect and interact to some extent. Nevertheless, the following dimensions are considered: physical health, mental health, spiritual health, emotional health, social health and societal health. Finally, the notion of holistic health is outlined and discussed as a means of bringing the different dimensions together as well as offering a new perspective on health which considers the ‘whole person’. Lay perspectives on health are intertwined throughout the discussion, drawing on research and evidence from around the world and taking into account the multitude of factors that impact on people’s ideas about health (for example, culture, age and gender).
The theoretical basis for thinking about health is provided in Chapter 3. This chapter starts with an exploration of Lalonde’s health field concept. Several other models are then introduced, discussed and critiqued. These include the biomedical model of health, the social model of health, the biopsychosocial model of health (Sarafino and Smith, 2022) and a ‘working model of health’ that brings together aspects of the preceding models (Green et al., 2019). Each model is described and outlined in detail. The chapter then moves on to consider non-western models of health as rooted within Indigenous understandings of health and well-being. These are considered in general terms before looking in some detail at Indigenous concepts of health in Māori populations in New Zealand and Indigenous communities in Canada.
Chapter 4 considers what determines health. It starts by exploring what is meant by the term ‘determinants of health’ and then moves on to introduce two models of social determinants: Dahlgren and Whitehead’s (1991) classic ‘rainbow’ model and the more contemporary framework provided by the Commission on the Social Determinants of Health (Solar and Irwin, 2010). The social determinants of health are discussed in relation to these two models. This includes consideration of structural determinants such as social class, gender and commercial determinants of health. The chapter examines health inequalities and inequity and draws on a range of international research to illustrate how health experience is inconsistent between, and within, countries in our modern world. This includes some discussion about responsibility for health, as well as issues of structure and agency. The seminal work of Sir Michael Marmot and his team is considered in some detail in this chapter, which ends with some final thoughts on how the social determinants of health might be tackled in order to create fairer health outcomes for all.
The idea of health as well-being is explored in Chapter 5, starting with an exploration of different definitions and concepts of well-being. It discusses Grant et al.’s (2007) three core elements of well-being – psychological, physical and social – as well as some other theoretical contributions, including that offered by Martin Seligman. The chapter draws on a range of research about well-being and health using lay perspectives as a basis for the discussion. The challenges of measuring well-being are considered, taking into account how ideas about it vary according to different social factors such as culture and race/ethnicity. The chapter includes an overview of the Geneva Charter for Well-being and ends with a brief discussion about quality of life.
In the past two decades happiness has become more generally linked to health and health experience in the broader literature. Some people would even argue that to be happy is to be healthy. Happiness indices now offer a way of measuring quality of life outside of economic means. Chapter 6 explores what happiness is and how it relates to concepts of what it means to be healthy. Happiness is considered firstly at the individual level and then at societal level. Happiness research is drawn upon throughout the chapter, and reference is made to relevant theoretical constructs of happiness. There is also some discussion of how happiness can be measured and achieved, drawing on narratives of health and happiness from the wider literature. The chapter concludes with a case study of happiness, health and social media.
Chapter 7 concerns the question of what makes people healthy. While the previous chapters consider several different perspectives on what health is and what determines it, in this chapter we turn our attention to what creates health. As well as giving due attention to action on the social determinants of health this chapter focuses more heavily on salutogenic perspectives and asset-based approaches to creating health. It begins with a brief discussion of policy approaches to tackling the social determinants of health, then moves on to Aaron Antonovsky’s theory of salutogenesis. The discussion draws upon global research and evidence from the wider literature about the effectiveness of salutogenic approaches to health, and suggests how these might be maximized for health gain, before moving on to consider asset-based approaches.
Planetary health affects everyone. The health of our planet and our own health are intricately connected. Chapter 8, the final chapter, locates the discussion about human health within the context of planetary health. It draws attention to the critical issues of our time, including climate change, overpopulation and threats of extinction. Discussing the concept of ecological health, it introduces some relevant theoretical constructs that seek to describe and explain the complex interactions between human health and the health of our planet. The chapter draws on Indigenous concepts that view human health as inextricably linked to planetary health and discusses how both might be addressed for the benefit of all. Finally, it discusses the future of human health over the next few decades in the light of current knowledge about human and planetary health, recognizing some of the challenges that are faced and how they might be overcome.
In each chapter you will find the following features to enable your understanding:
A set of aims outlining what the chapter will do.
Opportunities to ‘pause for reflection’, which will give you the chance to think about and reflect on the chapter contents in more detail.
A case study designed to bring aspects of the discussion in the chapter to life.
A summary section outlining the main points of the chapter.
A suggestion for further reading. This may be a paper, a book chapter or even a book.
I hope you enjoy reading this book as much as I have enjoyed researching and writing it.
1What is Health?
Chapter aims
To consider health as complex and contestedTo examine different definitions of health, including the World Health Organization’s classic definitionTo explore health as socially constructedTo highlight the importance of lay perspectives and lived experiences of healthIntroduction
This chapter considers the question ‘what is health?’ as a broad introduction the rest of the book. It provides the foundation for the subsequent discussions in the following chapters and sets the context for discovering the nature of health. The chapter starts by outlining why it is necessary to think about health in detail and to consider what health is, acknowledging from the outset that ideas about it are complex and contested. Different definitions and concepts of health from the wider literature are introduced and discussed, including the ‘classic’ definition offered by the World Health Organization. The chapter introduces different philosophies of health and ideas of what it means to be ‘healthy’, drawing attention to the complicated and debated nature of health and differing lived experiences. More critical debates about health are also introduced, such as health conceived as a social construct and as a moral phenomenon. Finally, the importance of lay perspectives on health will be considered, as a basis for this being a key theme throughout the book.
The importance of health
Why is health important? Perhaps you could take a few minutes to think about this. Is health important to you? If so, why? Most people, when asked what is important to them or what they value most, will mention health at some point. For some people health is the most important thing, viewed as an integral or essential part of life. After all, being healthy generally means experiencing life in a more meaningful, enjoyable way as well as enabling us to do what we desire. Health, however, is a nebulous concept, and what it means to one person is likely to be different to what it means to another (Tapper, 2021).
Health: complex and contested
The notion of health, then, is highly complex, and there are many ways in which it can be defined, understood and experienced (Cross, 2020). Although the word ‘health’ is frequently used, its meaning is often taken for granted or there is assumed to be a shared understanding about what it is. However, if you ask any number of people what health means to them you are likely to get different answers, although there may be some common themes in the responses. What we understand health to be is influenced by many factors, including where we live, our age, our gender, our health experience and status, the era in which we were born and so on.
One of the simplest ways of thinking about health is a dichotomous one – health can be viewed either positively or negatively (Green et al., 2019). Positive ideas about health tend to emphasize aspects such as well-being, happiness and holism. Such ideas encompass very broad perspectives on health and what it means to be healthy, taking into account the many dimensions of health (see the further discussion of this in Chapter 2). On the other hand, negative definitions of health tend to focus on not being ill, and the absence of disease or disability. Negative definitions therefore tend to be narrower, more focused on our physiology (the physical body), and rooted in the (bio)medical model of health that promotes scientific understandings about what health is. However, these definitions tend to overlook subjective perspectives on health: people’s everyday experiences, understandings and realities of health (Cross et al., 2017). So, health can also be viewed as socially constructed. We will consider this in more detail later in this chapter.
Health may also be seen as a value, as a right or as a responsibility. Mahatma Gandhi highlighted health as a value when he said in 1948: ‘It is health that is real wealth and not pieces of gold and silver’ (cited in Oleribe et al., 2018: npn), emphasizing the importance of health compared to being rich. Many people will put a high value on health when asked about the things that are important to them; however, health may not always be a priority, depending on the circumstances of a person’s life. The pursuit of health for its own sake will often come second to other more pressing concerns.
There is ongoing debate about health as a right and health as a responsibility. Many would argue that everyone has a right to health and, indeed, this is enshrined in the Universal Declaration of Human Rights (1948), which states in Article 25 that ‘everyone has a right to a standard of living adequate for the health and well-being of [themselves and their family], including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond [their] control’. Already we can see how this right to health encompasses many aspects of life. The right to health was recognized again in the 1966 International Covenant on Economic, Social and Cultural Rights (WHO, 2008), and health has more recently been highlighted in Sustainable Development Goal 3: Ensure healthy lives and promote well-being for all at all ages.
Nampewo et al. (2022) contend that the right to health is one of the cornerstones for enhancing and improving overall well-being and human development, and that there are many different stakeholders who have a significant role to play in this, including individuals, states, corporations and institutions, as well as the international community. Nampewo et al. argue that everyone has a duty to play their part and that this implies a responsibility too. Health as a right is reflected in the Constitution of the World Health Organization, which states that ‘the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being’ (cited in WHO, 2008: 5), ‘without distinction of race, religion, political belief, economic or social condition’ (WHO, 2023: npn). As we have just seen, the right to health is also reinforced in Article 25 of the Universal Declaration of Human Rights in relation to the right to an adequate standard of living. Many of the other articles in that declaration are also directly or indirectly related to the right to health. Most people acknowledge that, for anyone to achieve health, basic human needs have to be met first, such as shelter, food and basic sanitation (Capone et al., 2018).
Health can also be understood in terms of consumption and as something that can be bought through either goods or services (Aggleton, 1990). The framing of health as a market or consumer need that requires services and products (pharmacological, technical, financial, etc.) is compelled by the (bio)medical model (see Chapter 3 for more detail). More recently, ideas about health have been influenced by social media, where there is a daily proliferation of posts about healthy eating and physical activity that emphasize the idea of health as a project, as something to be improved or acquired (Baker and Rojek, 2019). Such ideas also promote notions of health as consumption.
What ‘being healthy’ looks like might vary from person to person, too. Humanist perspectives on health emphasize our ability to adapt, cope and achieve our maximum potential whatever that might be, recognizing that not everyone can achieve the same end results (Morilla and del Palacio, 2016). Such perspectives link health directly to ideas about self-actualization, self-realization and self-fulfilment (Svalastog et al., 2017), another area where social media can play a key role.
Professional and lay understandings of health may differ or have similarities; however, there is good evidence to suggest that lay understandings of health are often complex and sophisticated (Cross, 2020). This is despite the fact that, as Green et al. (2019) argue, lay perspectives are often undervalued and seen to be illogical, unsound and inconsequential compared to so-called expert opinion. The complexities and sophistication of lay perspectives on health will become apparent when we return to them later in this chapter and throughout the book.
Definitions of health
As Angela Scriven (2017) argues, it is very hard to define health. In fact, finding a universally agreed definition would be impossible. Nevertheless, there are several different ways of defining health that can aid our understanding of what it is, and of how people experience and make sense of it. Definitions of health vary considerably dependent on a range of factors. Some definitions construe health as being an objective reality that can be assessed and measured (usually by establishing the absence of disease, illness, distress or injury). Such understandings are grounded in positivist ways of viewing the world which imply that there is an absolute truth that is discoverable. Definitions of health that centre on the absence of disease or illness reflect this type of worldview.
In contrast, other definitions consider the fact that health is a subjective experience and that understandings about what health is are not just rooted in our physical being but extend far beyond this. In this sense health is understood as being socially constructed, as socially, historically, culturally and temporally located (Warwick-Booth et al., 2021). We will explore the idea of health as a social construction in more detail later in this chapter. Suffice to say here that, as sociologist Mildred Blaxter (2010: 35) argues, ‘health is not, in the minds of most people, a unitary concept. Health is multi-dimensional, and it is quite possible to have “good” health in one respect, but “bad” health in another.’ For some people it is impossible to define health given that it is an abstract concept (Earle, 2007: 38), amorphous (Oleribe et al., 2018) and elusive (Johnson, 2007). However, others have tried to define it. Psychiatrist Norman Sartorius (2006: 662) notes three types of definition as follows:
Health as the absence of any disease or impairment
Health as a state that allows the individual to adequately cope with all demands of daily life (implying also the absence of disease and impairment), and
Health as a state of balance, an equilibrium that an individual has established within [themself] and between [themself] and [their] social and physical environment.
The first type of definition is quite narrow, restricting health to the physical or biological domain, but it sits well with an objective view of the world and might also be described as ‘negative’, since it is based on what health is not. Negative definitions of health do tend be narrower, more concerned with health as the absence of illness, and, unsurprisingly, more disease-oriented. Conversely, as noted earlier, positive definitions of health are broader, more concerned with health as well-being or as an asset (Warwick-Booth et al., 2021).
The second type of definition locates health at the individual level as well, but with more of an emphasis on functioning. The third type of definition, however, broadens the notion of health, moving beyond the individual (body) to encompass the wider environment. Notably, this type of definition reflects ideas about balance or equilibrium which are often found in lay understandings of health (Bishop and Yardley, 2010).
Definitions of health may focus on different aspects of health. Some (as in the second type of definition above) are concerned with health as the ability to function, to do the things we want to and get on with living (Warwick-Booth et al., 2021). Other definitions of health position it as a commodity, something that can be consumed, bought, sold, given or lost (Aggleton, 1990; Bambra et al., 2005). Humanist definitions of health cohere around ideas of being able to cope, adapt and achieve our greatest potential, expressed as self-actualization, self-fulfilment or self-realization (Svalastog et al., 2017). In keeping with this approach, David Seedhouse (2001: 8) defines health as the foundation for achievement, stating that a person’s optimal health is ‘equivalent to the set of conditions that enable a person to work to fulfil their realistic chosen and biological potentials’.
Stokes et al. (1982: 33) defined health as ‘a state characterized by anatomic, physiologic and psychological integrity; an ability to perform personally valued family, work, and community roles; an ability to deal with physical, biologic, psychological, and social stress’. Oleribe et al. (2018) point out that this definition encompasses the notion of resilience, a concept that is often linked to mental health. Resilience is understood to be about our ability to cope with life’s stressors and adapt to what life brings.
Warwick-Booth et al. (2021) highlight the fact that trying to produce a definition of health that suits everyone is very difficult as health is conceived of, experienced and influenced in so many different ways. In the same vein, Seedhouse (2001) argued that the question ‘what is health?’ is a philosophical one because competing and contrasting ideas about health exist. Viewing health in this way allows for an appreciation of its complexities and for different definitions and experiences of health to co-exist: as Wills (2023: 2) argues, health ‘can embody a range of meanings, from the narrowly technical to the all-embracing moral or philosophical’.
Finally, as Scriven (2017) points out, it is important to appreciate that definitions of health change over time. They are constantly evolving as our understandings and experiences change too. How we define health will depend on many things, and, in that sense, health is highly subjective. Take, for example, our age. As we get older, we are more likely to consider health in terms of what we are still able to do, and in terms relative to our experiences of chronic illness – the chances of which increase with the years. Whether or not we are currently experiencing ‘better’ or ‘worse’ health will influence how we think about and define it (Tapper, 2021). Definitions of health have also changed over the course of human history as our knowledge of what causes and contributes to better health has developed. For example, before germs were discovered in the late nineteenth century, the cause of many infectious diseases was believed to be ‘miasma’ (literally: ‘bad air’). Similarly, before the carcinogenic effects of cigarettes were known, smoking was promoted for medicinal purposes (Charlton, 2004). Advances in science, medicine and technology have affected ideas about what health is and what causes disease. They are likely to continue to do so. Before you read any further, take some time out to do Pause for Reflection 1.1.
Pause for Reflection 1.1
As pointed out above, definitions of health are not constant, and they change over time. Can you think of any examples of this? Use the internet to research ideas of health in a specific era (for example: medieval, pre-industrial, post-industrial). More recently, how did the COVID-19 pandemic change ideas about health and how to stay healthy?
The contribution of the World Health Organization
The World Health Organization has played an important role in the development of ideas about health. Many will be familiar with the classic definition of health offered by the WHO in its constitution: ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity’ (WHO, 1948, cited in WHO, 2006a). This definition has a lot going for it. It is broad. It is positively framed, marking a move away from understanding health in a narrow, medical, disease-oriented way. It recognizes that health is more than simply not being ill. It takes into account mental and social health, and it brings in ideas about well-being. It locates health in subjective experience (McDonald, 2023). Notably, it promotes a holistic view of health as well.
This definition has stood the test of time quite well over the seventy-five years or so it has been around, but it has also come under fire for several reasons too. It is viewed by many as being unrealistic, impossible to attain and even utopian in nature (Huber, 2011; Lucas and Lloyd, 2005; Tapper, 2021). Such criticisms centre on the fact that no one could describe themselves as being healthy with this definition as their point of reference. It has also been criticized for not taking into account other dimensions of health. Whilst it references physical, mental and social health, it does not include other recognized dimensions such as emotional, spiritual or environmental health for example. Some people, such as Francesco Chirico (2016), have called for the WHO to revise its definition of health to include the spiritual dimension, but this has not yet happened. More than twenty years ago epidemiologist Rodolfo Saracci (1997: 1409) highlighted several shortcomings with the definition, stating that it was of no practical use and that it seemed to ‘more accurately define happiness than health’. Sartorius (2006: 662), among others, has pointed to a major problem with the definition in its failure to recognize that health can ‘co-exist with the presence of a disease or impairment’. More recently, Oleribe et al. (2018) have highlighted how the WHO definition is also hard to measure.
With reference to older people living with and managing chronic disease, Fallon and Karlawish (2019) argue that the WHO’s definition is not inclusive enough since it does not account for this part of the life course, and that it thus needs to be revised and updated. The world has changed a lot since the definition was first enshrined in the WHO constitution in 1948. At that point average global life expectancy was about 48 years for men and 53 for women (Fallon and Karlawish, 2019). People in many countries now live a lot longer than this: as of 2022, global life expectancy was nearly 70 years for men and just over 74 for women (World Bank, 2023). Fallon and Karlawish (2019: npn) argue that ‘having disease and feeling healthy are no longer mutually exclusive, especially for older adults’ (although by no means exclusively), such that many older adults are likely to describe themselves as being healthy despite living with chronic disease.
Philosopher Catherine McDonald (2023) points to the problematic use of the notion of completeness in the WHO’s definition. She argues that this is probably the biggest problem with it in that completeness is very difficult to identify and measure, is not a universal concept, and can be understood in different ways. McDonald (2023: npn) also points out that ‘while the inclusion of total well-being under the WHO definition of health is one of its attractions, it is also its greatest weakness. By including subjective well-being into the concept of health, the concept ultimately dissolves into a myriad personal subjectivities among which there is no obvious priority.’ She concludes that, ‘by attempting to include all aspects of life impinging on human well-being into the concept of health, the WHO definition ultimately becomes unintelligible’. Some would view this as a rather harsh critique; but McDonald has a point and similar observations have been made by others.
Despite calls to do so, the WHO has not yet revised its definition of health. Recently, however, others have attempted to do so. Writing in the Pan African Medical Journal, Oleribe et al. (2018: 3) suggest that health be defined as ‘a satisfactory and acceptable state of physical (biological), mental (intellectual), emotional (psychological), economic (financial), and social (societal) well-being’. They describe this as an all-encompassing definition, yet it does not include several aspects or dimensions of health that some people think are important; for example, spiritual and environmental health. However, they do go on to say that health is ‘the state of having the overall physical, mental, emotional, and social ability to add value not just to one’s self, but to society, resulting in the development of a better and sustainable world where things work, people live in harmony and community existence is enhanced’ (2018: 3). This, too, might be criticized for being idealistic.
Health as a social construct
We have already noted in this chapter that health can be viewed as a social construct, and this is the perspective which generally dominates the discussion in this book. Understanding health as socially constructed is an important consideration for definitions of health and for trying to understand what health is about. Social constructionist perspectives on health allow for subjectivity and reject the existence of an external ‘truth’ about what health is. From a social construction perspective, health is what people believe it to be and is defined by how people act and understand it. Viewing health in this way enables us to take into account the various different ways that people conceive of health and also to understand it as a fluid, organic concept (Warwick-Booth et al., 2021).
