Jonathan Metzl is a Professor of Women’s Studies and Psychiatry at the University of Michigan and author of Against Health: How Health Became the New Morality. Naomi Adelson is an anthropologist and author of ‘Being Alive Well’: Health and the Politics of Cree Well-Being. Both specialists agree that certain concepts are more easily defined negatively, and ‘health’ may be one of them.
The World Health Organization would say No. They define health positively:
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
With 88% of Americans qualifying as metabolically unwell (Araujo, Cai & Stevens, 2019), it seems a good time to reflect on how we define and measure health. A time to reclaim health as an individual and cultural value, and examine its individual and collective meaning.
Disclaimer: most of my experience takes place on the level of working with individuals.
From a neuroscience perspective, there is an important difference between avoiding a negative outcome, and pursuing a positive one. The coaching industry, which leans on positive psychology, encourages clients to define a vision, a why, and to act from inspiration, love and approach behavior rather than fear and avoidance.
I think both motivations (negative and positive) are worth keeping an eye on. Are we being healthy for health’s sake, or running fiercely from the alternative: a loss of autonomy or those memories of pain, helplessness or discomfort in our own bodies? Both positive and negative experiences can lead to increased resilience, depending on what we do with them. Fascinatingly, the neurobiology of positive emotions may undermine some of the assumed continuum between positive well-being and illness (Burgdorf & Panksepp, 2006), but that is for another blog post.
Most Americans still operate with a “conceptual link between health and disease”
Most Americans still operate with a “conceptual link between health and disease”, where “health is determined in proportion to a relative absence of disease, be it through the availability of medical services, the relative distribution of pathological environments or population norms and standards” (Adelson, 5).
Importantly, these measurements of health take place on the level of populations, not individuals. There is a predictability power in statistical analysis, but health trends on massive scales cannot be replicated at the level of the individual, and I wonder if this illusion of predictability encourages the American obsession with control over health, the idea that “If I follow general dietary guidelines and exercise regularly and safely, avoid obvious dangers, get vaccinated and bend my will power toward body advocacy, I have some kind of right to health in life.” But our control is limited by several factors, at least one being our history, as well as the socioeconomic and political climate.
One perfect example of having limited control over our own health might be the risk we all live with in the wake of nuclear technology. In his essay Atomic Health, How the Bomb Altered American Notions of Death, Joseph Masco points out how the nuclear revolution forced us to rethink health not as the opposite of illness, but as the best balance of many kinds and/or potentials for illness:
“We have moved from a notion of health as absence of disease to a graded spectrum of dangerous effects now embedded in everyday life. Health, as Kahn presents it here, is a statistical calculation rather than a lived experience, and it is precisely by approaching health as a population effect rather than an individual one that he creates the appearance of rationality”Masco, 137.
As a former math/ philosophy major, this appearance of rationality keeps me up at night. Some of us base life and death decisions on statistical arguments, such as, “Flying is statistically safer than driving, so I’ll get on this plane.” But it only takes one event to take a life, and at that moment of realization, statistics become irrelevant. Masco refers to Herman Kahn’s attempt to do a cost-benefit analysis on the many possible post-war states. Kahn’s decisions involved tricky “health” calculations, like pitting national security goals against a 1% deformity rate in children from nuclear radiation. So how do we interpret such percentages on the level of an individual life?
A calculative approach to health risks may project airs of confidence and medical progress, but it is certainly not the universal way to measure health. Naomi Adelson discusses the Cree notion of miyupimaatisiiun ‘being alive well’ (no word for health as we know it exists in the Cree language). For the Cree, the land’s health is bound up in our own. Adelson’s first chapter states it neatly:
“If the land is not healthy, then how can we be?”
The impact of Strontium-90, for example, would have been an obvious concern from a Cree perspective, since the environment decides the fate of the Cree people. For example, a good hunting season might signify nature’s approval of the Cree hunting and living practices; or when a Caribou is killed, the Cree believe that the spirit of the Caribou recognized the nobility of the hunter and chose to give up its body to him. This feedback cycle of respect for and worshipping of the earth which gives life to the people represents the intensely close, dependent relationship ‘being alive well’ has with the environment. And, in many ways, this basic understanding might contribute to well-being by simply being less abstract than the tricky health calculations that thrive in modern, ‘advanced’ academic society.
Various approaches to estimating one’s health lead to meaningful disparities between cultures. For example, the perception of fat in American culture vs. Cree culture is significantly different. Whereas we perceive any visible fat as excess and unnecessary, “ for the Cree, fat is such a valuable foodstuff that to consider it harmful verges on outrageous. In much the same way, to have excess fat on one’s body is, for the Cree, a sign of well-being, not a harbinger of future ailments” (Adelson, 104).
Lauren Berlant, one of the contributing authors to Jonathan Metzl’s Against Health, writes on the obesity epidemic in her essay Risky Bigness: On Obesity, Eating, and the Ambiguity of “Health”. She observes that in many cases of “fatness”, mental and physical health seem to be fighting each other, and food steps in to serve as a medicine for mental and emotional exhaustion (Metzl, 26). Food does not serve this medicinal purpose for the Cree; their relationship with food still bears traces of their ancestors’, who survived on the fat of bush animals. The Cree have had a positive, grateful relationship with food, though increased access to “white man’s food” is changing this relationship as diets accommodate the effects of increased access to modern foodstuffs, medicine, and health care.
The American perception of fat, though, as Berlant points out, is influenced by a culture of high productivity, one that relies on energy drinks, sugars and stimulating, often artificial foods in order to get through a work day. The Cree, who are constantly interacting with nature and each other, do not suffer from a lack of social interaction or living in the present. An American’s daily dose of this interaction might be during a lunch hour (never long enough) or on nights and weekends, and usually involves sharing a meal. Hence food becomes associated with social comforts. Still, to be fat is to be lazy to some extent, even though a person might ironically be working very hard, and therefore using food to compensate for when he/she needs rest for the mind and body.
Food isn’t the only medication available for the exhausted, productivity-focused American body. Medicalization and “diseasification” are everywhere: erectile dysfunction, ADHD, OCD, anxiety, sexual orientation, all kinds of broad categories exist that can potentially be labeled as diseases and treatable symptoms. In some cases biomedicine might be helpful, but when are these experiences best left without chemical treatment?
The scary part is when you’re not aware that both a disease and its cure are being marketed to you: “News, conversation, friendship, humanitarian aid: virtually anything can be used as a sales instrument, which is effective only as long as nobody realizes that a product is being sold” (Carl Elliot, Pharmaceutical Propaganda, Metzl, 95). Many of us take harmless supplements for our ‘health’, for example, but are they really necessary? What happens when our truly good institutions- charity work, the work of scientific journals and bioethicists- become corrupted by pharmaceutical agendas? Will good science and biomedicine be undermined? The effects of medicalization are far-reaching on every scale from the psychological to the genetic to societal. It is very possible that we are absent-mindedly creating a new race: one whose very genome is dependent on the substances and ideas that we sell under the guise of health and wellness.
A positive definition might involve a certain kind of resilience, subjective and objective well-being, and acceptance (even celebration?!) of existence, a degree of comfort in our own bodies and their habitats. Huber et al. has proposed this definition of positive health: ‘the ability to adapt and self-manage in the face of social, physical and emotional challenges’ and suggested a conceptual model comprising six domains (Prinsen & Terwee, 2019).
On the whole, positive measurement is still new, messy, abstract, and/ or difficult to validate. I am hopeful about the positive measurements such as heart rate variability and those being proposed by Martin Seligman and the team at University of Pennsylvania. As our knowledge of the microbiome improves, challenging our notions of “us” vs. “them” (microbes, etc), new ways to measure the total ecology of our health may emerge.
On the level of the individual, though, we can get specific, and that’s what makes health coaching magical. When we focus on the inner life, and lived experience, health is for the sake of playing with grandkids, climbing a mountain, writing a book, leaving a legacy..
Exploring what health is not, and listening to the alarm systems our body is equipped with, is a robust prelude to deciding – first as individuals and eventually as a culture – what it is.
Adelson, N. (2000). “Being Alive Well”: Health and the Politics of Cree Well-Being (Anthropological Horizons) (Illustrated ed.). University of Toronto Press, Scholarly Publishing Division.
Burgdorf, J., & Panksepp, J. (2006). The neurobiology of positive emotions. Neuroscience & Biobehavioral Reviews, 30(2), 173–187. https://doi.org/10.1016/j.neubiorev.2005.06.001
Joana Araújo, Jianwen Cai, and June Stevens.Prevalence of Optimal Metabolic Health in American Adults : National Health and Nutrition Examination Survey 2009-2016. Metabolic Syndrome and Related Disorders, 17(1) Feb 2019.46-52.http://doi.org/10.1089/met.2018.0105
Masco, J. (2010). “Atomic Health, Or How The Bomb Altered American Notions of Death.” In J. Metzl and A. Kirkland (eds.), Against Health. New York University Press, 133-156.
Metzl, J. M., & Kirkland, A. (2010). Against Health: How Health Became the New Morality (Biopolitics, 18) (1st ed.). NYU Press.
Prinsen, C., & Terwee, C. B. (2019). Measuring positive health: for now, a bridge too far. Public health, 170, 70–77. https://doi.org/10.1016/j.puhe.2019.02.024
WHO definition of health, Retrieved from https://www.who.int/about/who-we-are/constitution