Policies to improve health
In 1984 the World Health Organization advocated legislation, fiscal measures, organizational change, community development and spontaneous local activities against health hazards as methods of health promotion. One of the major targets of their health promotion programme was ‘Equity in Health’, meaning that everyone should have an equal opportunity to reach their full health potential. It does not mean eliminating all health differences but rather reducing those deemed avoidable or unfair.
Health promotion is often focused on changing behavioral risk factors and appears as ‘health education’ and ‘social marketing.’ Social marketing is the systematic application of marketing to achieve particular behavioral objectives for social good. It is used to promote ‘merit goods’ and discourage the consumption of ‘demerit goods’. Examples of social marketing include campaigns to promote the wearing of seatbelts and to discourage smoking and to inform people of the relationship between sunbathing and skin cancer.
The promotion of a healthy lifestyle has also become a major media issue that goes far beyond guidelines concerning diet, fitness and awareness of health issues. Nowadays it promotes a culture of youthfulness, beauty and wellbeing via a multitude of treatments, procedures, pills, supplements, diets, exercise regimes, exercise equipment and alternative medicine plus an inordinate amount of health and fitness associated products. This type of promotion is commercial marketing aimed at those who are able and willing to pay for the goods and services.
Healthy living and a healthy lifestyle however does not need to be expensive. Education and the promotion of the fundamentals of good health should be a global initiative undertaken by all governments along with specific strategies to provide poorer communities with the basic requirements to enable them to adopt healthier lifestyles.
· By contrast, to health illness refers to imbalance. Something is out of sync. This can be understood in terms of judgments about what constitutes the normal and abnormal (Lock, 2000). These judgments are made in terms of biomedical tests, individual perceptions of ‘I don’t feel well’ and the social construction of the abnormal. Like the analysis of health, an examination of illness can take place on the level of the diseased organ, the individual, the community or the nation. While discussions of pathology dominate the medical literature, social scientists point out that illness is culturally constructed and closely associated with the dominant social, political and moral order (Turner, 2000). Their argument is that regardless of the organic basis of disease, the cultural context and interpretation of illness has profound implications for an individual’s sense of well‐being and perceived attribution of responsibility. When we say, ‘He is sick’, we employ a rich metaphor which means much more than the person has been judged to have an organic pathology determined by biomedical tests. We mean that the person is out of balance judged from our perspective.
· Theories of illness have been based on imbalances in the body, in the person or in social relationships. The great healing systems of India, China and Europe, for example, are based on the analysis of and interventions in such imbalances. Ayurvedic medicine is based on the Hindu belief that the body contains three elementary substances representative of the three divine universal forces they call spirit, phelem and bile. These forces are comparable to the Greek ‘humours’ of blood, yellow bile, black bile and phlegm grounded in the four elements of fire, earth, air and water. In traditional Chinese medicine, there is a dualistic cosmic theory of the yang (the male force) and the yin (thefemale force). The body is made up of five elements: wood, fire, earth, metal and water. In these systems, specific illnesses were attributed to an inordinate amount of one force, element or humour. For instance in the Greek system, colds in the winter were due to phlegm and diarrhea in the summer to bile. In these three theoretical systems, illness depended on preservation of balance between these forces and it was the task of the healer to bring these forces into equilibrium.
o In a review of ethnographic data from 139 societies intended to sample the world’s cultures, Murdock (1980) argues that an understanding of illness and by implication of health, across cultures can be based on theories of natural and supernatural causation. According to Murdock (1980: 9), theories of natural causation consist of ‘any theory, scientific or popular, which accounts for the impairment of health as a physiological consequence of some experience of the victim in a manner that would appear reasonable to modern medical science’. Natural causation explanatory frameworks include theories of infection, stress, organic deterioration, accidents and overt human aggression. The germ theory of illness, for example, which drives Western scientific medicine, would fall under a natural causation model emphasizing infection.
§ The theories of the supernatural causation of illness rest on assumptions that scientific Western medicine does not recognize as valid. According to Murdock’s (1980: 17–27) analysis, there are three general types of theories of supernatural causation:
1. Theories of mystical causation
2. Theories of animistic causation
3. Theories of magical causation.
Theories of mystical causation are ‘any theory which accounts for the impairment of health as theautomatic consequence of some act or experience of the victim mediated by some putative impersonal causal relationship rather than by the intervention of a human or supernatural being’ (Murdock, 1980: 17). Some examples are the notion of ‘fate’ among the Romans and the breaking of food or sex taboos among the Thonga. Theories of animistic causation are ‘any theory which ascribes the impairment of health to the behavior of some personalized supernatural entity – a soul, ghost, spirit or god’ (Murdock,
1980: 19). An example is the concept of soul loss among the Tenino Indians of Oregon State in the United States. Theories of magical causation are ‘any theory which ascribes illness to the covert action of an envious, affronted, or malicious being who employs magical means to injure his victims’ (Murdock, 1980: 21). An example is the concept of the ‘evil eye’ invoked in Mediterranean cultures to explain illness and death. Each of these theories deals with the issues of:
· Agency: Who or what is causing the illness
· Social role: What is the role expected of the patient and of the healer?
· Symbols of knowledge, power and healing: What is the knowledge base of the healer? What symbols distinguish the healer from others in the community? and, What does purging by sweating or colonic therapy mean?
· Structure, process and outcome: Where should one seek help when ill? How does the healing take place? And, How should the healers be treated if they succeed or fail in their endeavors? (Ackerknecht, 1971; Porter, 1999).
· Murdock (1980: 88–95) found that nearly 80 per cent of his sample had a notion of mystical retribution expressed through a sense of sin; the belief that acts in violation of some taboo or moral injunction would be followed by punishment of the individual or group which is the cause of their illness.
· Malinowski (1944, 1948) made a major contribution to our understanding of theories of illness and help seeking by analyzing how individuals seek help for illness or seek to restore balance when things are out of sorts. In his examination of the workings of magic, science and religion, Malinowski concluded that individuals seek help for maladies according to their cultural and societal frames. What they have learned and experienced gives meaning to and a sense of control over their illnesses. Malinowski and others also discovered that people can use multiple frames of reference in understanding disease and seeking help. For instance, among the Wakomba of Kenya, individuals would often seek help from their medicine man if they were ‘sick’. But if that did not work, they might visit a health clinic to try Western scientific medicine delivered through a colored pill or injection by a doctor in a white coat. If the intervention of the medicine man and the doctor did not work, they might turn to their indigenous belief system or to the Christ of the missionaries. Often these approaches for help and interventions are commingled, with no one healer knowing that the others are being simultaneously invoked.
· While health is defined either as an ideal state or absence of disease, illness is the subjective experience of feeling unwell.
· Defined by Radley, “Illness can be taken to mean the experiences of disease, including the feeling relating to changes in bodily states, and the consequences having to bear that ailment; illness therefore, relates to a way of being for the individual concerned”.
· Illness therefore is what the individual senses that is ‘wrong’ with him or her, and may lead to making an appointment to see a doctor. Disease is what the individual has wrong with her or him on the return from that appointment.
· According to Cecil Helman (2007), a wide variety of subjective evidence is involved in the process of defining oneself as ill. These perceived alterations can be in physiognomy (for example, loss of weight), bodily emissions (for example, urinating frequently, or diarrhea), the working of specific organs (for example, heart beating fast, or headaches) or the emotions (for example, depression or anxiety).
· Helman (2007) describes the social context of illness. According to him, one cannot really understand how people react to illness, death, or misfortunes without an understanding of the type of culture they have grown up an or acquired – that is, of the ‘lens’ through which they perceive and interpret their world. So it is necessary to understand social organization of health and illness in that society which includes the ways in which people have become recognized as ill, the ways that they present this illness to other people, the attributes of those they present their illness to, and the ways that illness is dealt with.
· A ten‐point inventory of reasons why people proceed from feeling ill towards being diagnosed as diseased was formulated in the 1960s by David Mechanic, a founder of sociological analysis of health/disease. Mechanic realized that there are many psychological and social phases before a person is diagnosed as suffering from an objective medical condition. For Mechanic (1968) the factors affecting an individual illness will depend on whether or not symptoms:
i. are highly visible and recognizable;
ii. are regarded as serious/dangerous;
iii. disrupt working and family responsibilities and other social routines;
iv. repeat or persist;
v. breach the sufferer’s tolerance level and /or that of others;
vi. are understood well in terms of cause, treatment, and prognosis;
vii. are feared greatly or feared only minimally;
viii. figure high in the individual’s hierarchy of needs when compared with other priorities;
ix. are interpreted as with other normal activities rather than disease;
x. Can be treated easily in terms of available resources and time, and without embarrassment.
· In his study Morrall (1998) pointed out that the process of ‘feeling ill’ is not only dependent on the beliefs and actions of the individual, which in themselves are affected by social factors, but also upon behavior of disease‐care practitioners.
· The term ‘sickness’ denotes the amalgamation of the two processes of feeling ill and being diagnosed as diseased. It alludes to the existence of a social role especially following a diagnosis, and that are obligations and rights that society confers on diseased individuals
· The social features in maintaining of health and the manifestation of disease is irrefutable. As, Marx describes that appalling social conditions experienced by the poor living in the large industrial cities of that age. He connected the cause of morbidity and mortality among the inhabitants of the slum areas, factory workers, and the unemployed to these social conditions.
· Engel’s treatise accounts of how disease cannot be simply understood in terms of biology and pathology. Engels lays the blame for illness on the way in which (capitalist) society is structured, and in particular on the bourgeoisie.
· A study conducted in the late 1990s of the Indian city of Mumbai recorded how the systematic clearance of slums areas for new commercial and residential developments was responsible for eviction of 167,000 people. The children of these slum dwellers have protracted nutritional deprivation, diarrhea, respiratory disease, and skin infections, which were linked to the transitory nature of their residence and the effect this has on the family finances.
· The relationship between socio‐economic inequalities and disease inequalities within rich countries is reified in the life expectancy figures with those at bottom of the socio‐economic hierarchy dying younger than those at the top, children born into families of low socio‐economic status having a much higher risk of death before five years ago.
· The social selection perspective suggests that the lower classes those with meager employment and educational, material deprivation contain most of the unhealthy people in society. Those with physical and mental disease will ‘drift’ into the disadvantaged stratum of society as a matter of course. The physically and mentally advantaged will maintain good health and gain social superiority. Self‐evidently, the uneducated and unemployed, living within poor housing within disruptive communities, are more likely to be ill than are people with high educational and occupational attainment living in expensive and gated residential areas.
· Marmot et al. (1984) have demonstrated that occupational status is a robust predictor of life‐ threatening conditions. Certain work‐based psychosocial factors, such as autonomy and variety or direction and monotony as, experienced by employees, appeared to be critical for good or bad health.
· The Whitehall study (a classical longitudinal research study of the structuralist perspective on analysis of health and diseases) established clearly the relationship between position in social hierarchy and morbidity and mortality. Evidence from this study implies that relative deprivation rather than absolute deprivation is significant determinant of morbidity and mortality. The lower the grade of employee, the higher the death rate.
· Sir Michael Marmot, professor of Epidemiology and Public Health explains the interplay between structural condition and illness. According to him social conditions such as education, nature of jobs, living conditions like housing and availability of adequate nutritious food, quality of health care are the determinants of health and illness.
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