I feel the need to start this post with an acknowledgement of the gap since my last post. Whilst I don’t pretend to think there are people out there missing my blogs – I’m more worried about the number of streams of thoughts I have had which have come and gone and are unrecorded. It’s all because I’ve been busy keeping up with the reading and discussion forum for my PhD modules – and the assignments. I’ve also worked with two others to plan, design and facilitate the first ever Open University Systems Thinking in Practice alumni and friends get together – which was great. The formal taught work for my PhD finished today, I’ve got one more assignment to do – and then hopefully can use the summer to consolidate some of the material I have covered through blogs. It’s been a great journey, just haven’t had time to stop and take stock of it on the way.
Anyway, back to the real reason that I started blogging today. It was prompted by a seminar I participated in last Monday. Newcastle University, Sheffield University and NEF have got some funding to run a series of seminars on the ‘Politics of wellbeing‘. It is essentially people from the discipline of political science coming together to consider what the discipline offers to the ‘shift’ towards wellbeing in policy and politics – both in a critical and a constructive way. This seminar was the second in the series and I was asked to speak.
Preparing the talk led me to articulate and make explicit something that had been going on in the back of my mind for a long time.
The phrase ‘health and wellbeing’ has been used so long in the world of health, health services and social care that you often don’t spend much time thinking about why both words are used rather than just one of them. In fact I ended up saying at the seminar that I thought ‘health and wellbeing’ had been used for so long as a phrase that they have started to merge together as if they are one construct and not two. In Newcastle, we’ve played with the phrase a little – swapped the words around to ‘wellbeing and health’ – a rather symbolic way of illustrating that to stakeholders locally, wellbeing has primacy. But we still don’t often stop long enough to consider what that then means.
But, as I’ve thought about it I’ve grown to realise that, in using the two words together, our understanding of ‘wellbeing’ is influenced by our understanding of ‘health’.
There was a time when ‘health’ was considered the business of health care and because there was such an emphasis on health and social care services, it was generally thought that the word ‘wellbeing’ was a nod towards what social care achieved. I think we’ve moved on from that generally now – the greater recognition of the social determinants of health (and wellbeing?) – means that most of the time it is intellectually recognised that action involves a greater number of sectors and policy areas, even if in practice we sometimes default back.
So how do understandings of health play out – and how do they then impact on understanding of wellbeing.
The so-called negative conception of health understands health in terms of what it isn’t – i.e. a lack of disease. This understanding is quite institutionalised. For example, measures of health at a population level concern things like cancer incidence or COPD prevalence or even mortality information. The idea then is reduce those incidence/prevalence/mortality figures – a ‘healthy’ population is deemed to be one with low disease rates that doesn’t die early. It also impacts on who we think should act – disease gets treated/cured by the health service – they are the people that restore diseased (i.e. unhealthy) people to the state of healthy (no longer diseased).
This negative conception is also apparent in the ‘lifestyles’ discourse – smoking, low level of physical activity, poor nutrition, elevated body weight, high alcohol consumption are all talked of in terms of the ‘risk’ they create for disease. So too are some of the more social causes – loneliness, child poverty, homelessness. Here to be a ‘healthy’ population or a healthy individual is to be low on risk for disease.
So if in the phrase ‘health and wellbeing’, health is understood through a negative conception – what is wellbeing? It kind of offers some sort of counter-balance – makes you think of some sort of continuum – disease – risk of disease – neutral state (health) – wellbeing. There is a problem with this though not everyone with a ‘disease’ would say they have low or no wellbeing. And some individuals would report that ‘risky lifestyles’ such as smoking and drinking enhance their wellbeing.
Before I move away from the negative conception, there is another angle I’ve sometimes spotted. The term ‘health’ can be strongly associated with lack of physical diseases – like cancer or COPD or liver disease or diabetes. This raises a problem for those advocating for mental health (in the sense of lack of mental illness) – sometimes the word ‘wellbeing’ is used as an acknowledgement of mental health. In other words ‘health and wellbeing’ means ‘no physical disease or mental health illnesses’.
The positive conception of health is different. Most discussions of this conception start with the WHO’s articulation of health that is embedded in its constitution (1946) – “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”. This equates the word health with the word wellbeing – in other words the phrase ‘health and wellbeing’ is a tautology, you are saying the same thing twice (like I just did!!). There’s been a lot of discussion about this definition of health – or perhaps utopian vision – does anyone really ever attain ‘it’? They have also been some comments that even though WHO defined health in this way, it has never really established a set of measures that look at wellbeing (positive conception) instead focusing on sophisticated quantification of disease rates and risks.
But the WHO’s discourse has changed a little. In the Ottawa Charter (1986), health is referred to as a ‘resource for life’ – not the objective of living. And in the WHO European Regions recent new policy ‘Health 2020’ (2012) – it talks of health as ‘integral to’ wellbeing. Those alternative conceptions don’t seem to be filtering into the mainstream though.
So where am I left – ‘health’ and ‘wellbeing’ are seen as two good things – they seem to go hand in hand – I could tie myself in knots trying to separate them – and for the most part at the level of generalities things that are good for health are good for wellbeing. Is it worth many more word-games I don’t know?
But elsewhere – away from the discourse of public health, health care and social care – ‘wellbeing’ isn’t being used in such direct association with health and has therefore developed in other directions.
In the growing ‘beyond GDP’ trend, economists and policy makers have recognised the limitations of measuring societal progress through GDP. The economic ‘wellbeing’ of a country is no longer seen as representative of the ‘wellbeing’ of that nation let alone the ‘wellbeing’ of the citizens that live within it. This has led to a flurry of initiatives to develop ‘measures’ of wellbeing. The OECD for example have looked at the Better Life index at national level and the How’s life in your region for subnational levels. And in England, the ONS have worked on ‘measuring wellbeing‘ following Cameron’s announcement of the importance of measuring what matters.
The interesting thing here is that wellbeing is becoming defined in terms of how it is measured (in the same way that intelligence is often seen in terms of what an IQ test measures). There are few ‘new measures’ being put into place to support this agenda. In the ONS work for example – with the exception of the addition of four ‘subjective’ wellbeing questions to the annual household survey – all of the others are re-cycled measures we’ve seen for a long time – life expectancy, unemployment and so on. Wellbeing is becoming the latest banner term heading up a list of social indicators, following phrases such as quality of life. It is becoming defined in terms of a series of constituent components/dimensions – wellbeing equals ‘having a job’ plus ‘not having a disease’ plus ‘living a long time’ plus…the list goes on.
BUT…STOP…this risks us forgetting that wellbeing is an emergent property of the dynamic interaction of a range of factors both at a point in time and over time (at least that is how I perceive it – see this blog). It also risks us forgetting that wellbeing is incredibly subjective – it is something experienced and in my mind that is not a quantifiable phenomenon (do you ever quantify other experiences such as ‘love’?).
And there we are… wellbeing is contested; it is being used symbolically and as part of political rhetoric. The question is – will its use and discussions about it move our society on, help it shift to a new paradigm? As a ‘jury’ member I abstain, as a citizen I am hopeful.
I haven’t referred to any specific references in this piece but do want to acknowledge some works that have helped my thinking along…