8 Health and Well-being

Human survival depends on maintaining a certain level of health. But what exactly is health? How do we define and experience health and well-being? Given the shared instinct for survival across continents and generations, health might seem like an objective concept with clear universal values supporting it. However, anthropological perspectives have demonstrated time and time again how profoundly health and well-being are shaped by a combination of biology and environment as well as social, political, economic, and cultural factors.

In this chapter, we delve into some core concepts from medical anthropology. While medical anthropology is perhaps one of the better-known subfields within cultural anthropology today, its roots began long ago. For example, in the early 1900s, WHR Rivers wrote “Massage in Melanesia” (1926) where he recounted his observations from working in the Solomon Islands. There, he saw how local medical providers treated patients in ways familiar and unfamiliar to him. For example, one patient received an abdominal massage similar to what one might have received in Europe for the diagnosis of chronic constipation. While the presenting issue and treatment were familiar, Rivers noted that the treatment’s objective was to destroy an octopus which was the cause of the pathology according to an etiological understanding of Solomon Islanders. Across a variety of examples from his time in the field, Rivers writes that his goal was not to gaze with romantic curiosity nor with judgement but simply to point out the “basic difficulty which confronts those who attempt to trace out the origins of medical beliefs and practices.” He adds, “Medicine is a social institution. It comprises a set of beliefs and practices which only become possible when held and carried out by members of an organized society, among whom a high degree of the division of labour and specialization of the social function has come into being” (17).

While healing and health have existed and continue to exist in societies around the world, a major shift in dominant discourse came during the Age of Enlightenment in the 17^th and 18^th centuries. During this period, there was an emphasis on visualizing, seeing, or observing phenomena. Knowledge needed to be affirmed through direct empirical data. New technologies like microscopes and telescopes facilitated this process in the sciences but also created a foundation in which that knowledge which was not accessible via these criteria were excluded from biomedical models or scientific medicine. We can see how these histories and legacies endure today. For example, Complementary and Alternative Medicine (CAM) such as acupuncture may be widely accepted in some circles within the U.S. but medical payment models denote it as alternative and therefore outside of reimbursement structures.

Methods that emerged out of the 17th century began to frame what was at stake in knowledge production and scientific claims. For example, Robert Boyle argued that experimental methods were key to the ability for “gentlemen” to witness phenomena and agree upon objective facts. Thomas Hobbes, whom you may remember from earlier chapters for his perspectives on political economic structures, argued that experiments were artificial vacuums and produced in exclusive circles (Shapin and Schaffer 2018). These debates deeply shape how scholarship and popular discourse in the West framed today’s Eurocentric notions of health, medicine, and well-being.

At the intersection of the biological and the cultural, anthropologists can help us better understand the experiences of the sick and the healthy, and the communities that support and individuals through the ups and downs of wellness and illness. Medical anthropologist Dana Walrath writes:

Biomedicine locates sickness in a specific place in an individual body: a headache, a stomachache a torn knee, lung cancer. Medical anthropologists instead locate sickness and health in three interconnected bodies: the political, the social, and the physical. The prevailing political economy impacts the distribution of sickness and health in a society and the means available to heal those who are sick…Some cultures locate sickness not in individuals but instead in families or communities. As any caregiver knows, we live the sickness too (2016, 15).

Anthropological perspectives allow us to revisit how these belief models came into being while also exploring other models that shaped knowledge, beliefs, and practices around health around the world.

Biocultural Perspectives

In the edited volume Building a New Biocultural Synthesis (Goodman and Leatherman 1998), biological and cultural perspectives converge in a series of case studies that demonstrates the utility of a hybrid biocultural perspective. This is an example of bringing together two of the four fields we discussed earlier in Chapter 1. While not all medical anthropology is biocultural in framing, the concept is foundational to the subfield because it emphasizes how issues related to human health and well-being are grounded in biological realities. These case studies show how political economy and group structures can affect human biology; examples include cultural impact on nutritional status, spread of disease, and exposure to environmental toxins.

In “Report on the Typhus Epidemic in Upper Silesia,” Rudolf Virchow (2006) noted how miners and their families suffered from typhus in direct linkage to social conditions such as poor housing, working conditions, poor nutrition, and the lack of sanitation. More recently, researchers have underscored how more macro shifts in a country’s economy drive people to work in unhealthy environments linked to disease incidence rates. One example includes workers who contracted malaria while working in mines in Venezuela (Case 2016). When the Venezuelan economy began to collapse, middle class employees found themselves without means to support themselves. People from all walks of life and a range of social classes began to search for gold in Venezuela’s mining regions which were also areas with standing pools of water. Although malaria was reported to be eradicated in the country decades ago, this combination of human exposure, insect proliferation in an environment conducive for breeding, and political-economic upheaval led to a resurgence. As people returned home from the mines, they also carried back malaria which then spread in more densely populated towns or cities.

Another example of how biocultural perspectives in anthropology can help illuminate our understanding of health is Andrea S. Wiley’s Re-imagining Milk (2012). Wiley explores milk as both a biological source of nutrition across mammals, including humans, but also a product that is highly contextualized as a commodity form in contemporary America. Campaigns encouraging the drinking of milk in order to achieve and maintain healthy bodies often ignore the fact that a sizeable percentage of the population are lactose intolerant. Wiley delves into the shifts in milk consumption and how they have varied across time and regions based on evolutionary adaptations to both physical and social environments, stressing the ways in which biocultural perspectives can help us understand something as “simple” as drinking milk and complicating norms such as “milk: it does a body good.”

Scholars have also noted how health issues play out in racialized terms as a result of segregationist policies and practices. Recall our discussion of Clarence Gravlee’s work on the more recent COVID-19 outbreak and its intersections with historic and present-day systemic racism. Bringing this contemporary example together with our review of the history of scientific racism discussed in Chapter 5, we see how there is the need to carefully examine the distinguishing line between specific practices and policies that lead to racial inequities versus a naturalized notion that perpetuates the idea of inherently stronger and weaker subpopulations.

These residual beliefs linger today in the production and publication of knowledge, as evidenced by the recent call for scholars to clearly write in ways that differentiate race and racism in “On Racism: A New Standard for Publishing on Health Inequities” (Boyd et al. 2020). In fact, we can see present day slippages from mistaking a discussion about social conditions and structural inequities that impact population health to narratives about inherent differences in health. Leatherman and Jernigan write, “As each of these dimensions converge in vulnerable groups, the very conditions that give rise to disparities are likely to persist and perpetuate a dialectical interaction of inequalities and health. In short, the goal is to link macro structures to local biologies in local contexts, utilizing ethnographic and biological field methods to expose and examine the grounded processes linking vulnerabilities and health. Attention is on how structural inequalities ‘get under the skin’ to become embodied in biology and health” (2014, 176-177). A biocultural perspective and the tracing of case studies from anthropologists around the world is a useful means of understanding how we experience health as well as how we talk about health outcomes and goals for society writ large.

One example where a biocultural perspective illuminates both the complex causes of disease, barriers to health, and poses possible interventions is Type 2 diabetes. Type 2 diabetes is a chronic disease that impacts how the body metabolizes sugar. While Type 1 diabetes occurs when individuals do not produce insulin on their own, type 2 diabetes occurs when the body does not produce insulin as well as it ought to. In a global initiative to address diabetes, Novo Nordisk, Steno Diabetes Center Copenhagen, and University College London have led a network of anthropologists across multiple countries and continents who are using qualitative methods to better understand the rise of diabetes in urban landscapes around the world. One of factors that increases risk is increased body weight or obesity. Researchers describe how increasing urban environments have changed how people work, live, eat, and move around so that they consume more energy-dense foods with lower levels of physical activity (Novo Nordisk 2017). Throughout a year of field research conducted across multiple sites where 75 researchers based in five major cities (Mexico City, Copenhagen, Houston, Tianjin, and Shanghai) conducted a total of 746 interviews, key themes impacting diabetes were identified.

(NOTE: Collaborative anthropology is increasing in subfields like medical anthropology, distinct from tropes of the lone ethnographer in the field that we once saw in the discipline. We also see this practice emerging in subfields like visual anthropology, the anthropology of finance, and applied anthropology related to user experience or UIUX. Partnerships between funders, research institutes as standalones or as arms of other groups, and universities offer opportunities for a more publicly visible anthropology while also complicating the connections between research endeavors.)

While the themes are common across sites, the particular ways in which they expressed themselves are grounded in their local cultural context. Social factors include financial constraints, time constraints, resource constraints, and geographical constraints. Finances can affect access to health care or healthy food as well as increase levels of stress. This is distinct from resource constraints which refer to access to levels of education or knowledge about how to navigate existing resources in the landscape as well as a general lack of resources. One way to think about this might be the ability to afford healthy food combined with living in a food desert which limits the amount of health options that are available. Time constraints refer to work demands including commute times and the amounts of stress and isolation that can come from the busy pace of living in cities. Geographical constraints refer to environmental factors which can range from climate to public safety and built environment. Additional cultural factors include traditions and conventions, perceptions of health and illness, sense of self and others, and experiences related to change and transition. Industrialization changes both the landscape and human relationships, often moving individuals further away from extended family networks. Major political changes and lingering memories across generations can also impact attitudes toward food; one example would be experiences of food scarcity, famine, and hunger in China among people who lived through the Cultural Revolution and how that might affect attitudes toward food for themselves and how they feed their children or grandchildren in a new context of more energy dense, abundant food.

Another example of illness and health that is illuminated through a biocultural perspective is sickle cell anemia. In the 1950s, Frank Livingstone began studying sickle cell anemia in Liberia. He found that a surprising lack of sickle cell anemia present in this West African region where malaria is prevalent. In biological anthropology, the presence of sickle cell anemia is often explained as adaptive for an environment where malaria is a greater danger to health. He published his findings in “Anthropological Implications of Sickle Cell Gene Distribution in West Africa” (1958) including an explanation of this puzzling phenomenon, namely that malaria itself was recent arrival to Liberia so that the prevalence of sickle genes as a slow process of natural selection had not yet occurred. The recent rise in malaria in the region was further associated with deforestation which then contributed to an environment conducive to mosquito breeding, allowing malaria transmission to increase. Subpopulations within Liberia had only recently adopted more large-scale agricultural trends, having previously followed more of a hunter-gatherer subsistence strategy. Changes in subsistence strategies effected forest density and the mosquito population, leading to sudden increases in malaria where there had previously not been (but without the time scale to lead to higher presence of sickle cells). A biocultural framework allows us to see increases in disease prevalence such as sickle cell anemia and malaria from both biological and cultural perspectives, noting how human behaviors and practices impact environment and then circle back to impact experiences with illness and public health.

As we discussed in our chapter on gender, the body and the norms that surround it have been an important topic of study in anthropology. Nancy Scheper-Hughes and Margaret Lock explore three ways in which we can understand perspectives about the body in their piece, “The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology” (1987). They include: 1) the individual body-self; 2) the social body as a symbolic means of thinking about relationships in culture and society; and 3) the body politic as an artifact of political and social control. Other anthropologists like Rayna Rapp have demonstrated how the growth of medical anthropology since the 70s and 80s have interacted with feminist activism and gender studies. Rapp specifically argues that “feminist attention to embodied inequalities quickly focused on reproduction as a site of investigation and intervention. Medical anthropology has benefited from feminist concern with stratified reproduction, especially its interrogation of nonnormative and stigmatized fertility and childbearing” (Rapp 2001, 466).

Defining Health and Well-being

One way of articulating anthropological perspectives on medicine has been through ethnomedicine. Ethnomedicine refers a subtopic within medical anthropology. It is the study of different cultures ways in which societies think about health and illness, and how they act with regard to health and healing (Quinlan 2011, 381).

In the 1980s, Arthur Kleinman popularized the notion of an “explanatory model” where every illness has multiple potential causes and descriptions. By combining multiple factors, people create a “model” that explains how someone might get sick and any encounter. Between a physician and patient who might even live in the same society, having this reference point can create space for conversations that can shed light on similarities and differences between models. This contribution can be seen today as medical providers are taught to be aware that such differences might exist, rather than presuming or assuming sameness, resulting in the integration of cultural humility lessons during education and training. In his discussion of explanatory models, Kleinman also noted that different societies will emphasize aspects of health and illness based on other values that are important to that culture. For example, Western models might frame disease using war and invasion as metaphors, underscoring the invasive power of pathogens and the immune systems battle against intruders while Taiwanese models might emphasize being hit by spirits (Kleinman 1980).

Ethnomedicine and its popularization informed medical training in cross cultural contexts so that different explanatory models would not shut down important conversations between medical practitioners and patients. At the same time, there was a rise in describing conditions as culture-bound syndromes and associating a set of beliefs to a particular group of people. In addition to the specific case studies of describing illness, anthropological studies also focused on different modes of healing to treat various conditions of the mind, spirit, and body.

While shedding light on other ways of understanding health and healing can broaden understanding, an overemphasis on different beliefs and practices can also result in Othering nonWestern people. For example, Kwasi Konadu writes about the persistent focus on “witchcraft” in ethnographies. Konadu argues that the “failure to locate African perspectives on the substance of such realities in African societies, and that failing emerged from a quest for ‘ethnographic cases’ and issues of ‘witchcraft’ and ‘supernatural’ etiologies in the field of medical anthropology rather than the field of African knowledge and perspectives” (2008, 60). Newer and more recent studies within medical anthropology aim to address some of the pitfalls of the discipline’s history and more recent ethnographies, whether situated in Africa on other continents, underscore local contexts that complicate the notion of one institution-based medicine (e.g., hospitals and licensed medical doctors) in the West and “folk” healers in non-Western contexts. For example, Laura Foster writes about legal agreements and scientific patents in the development of an anti-obesity drug that utilizes an indigenous herbal plant called Hoodia (2018). Foster describes an agreement between the South African San Council and the Council of Science and Industrial Research as a way of understanding how scientists, farmers, and indigenous people (the San in this case) converge in the space of pharmaceutical development and the pursuit of wellness.

Additionally, part of defining health is to understand what it looks like and feels like to be ill. French historian and philosopher of science Georges Canguilhem describes how certain states and traits came to be regarded as normal and others as pathological (1991). Canguilhem demonstrated how these categories came to be constructed in relation to one another rather than taking either as objective fact. The normal and the pathological emerged out of particular social and historical contexts. This is not to say that illness is “not real” or some kind of made-up narrative but rather, that the distinct lines between categories are often not as straightforward as we would like them to be. One example is the ways that diagnostic categories and symptoms have changed over time when reviewing the evolution of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Building on Canguilhem’s work, theorists such as Michel Foucault and a series of contemporary critical psychologists have provided ethnographic examples as a means of critiquing diseases or behaviors labeled pathological based on the idea that political, economic, and social contexts shape ways of knowing and being.

Geoffrey Bowker and Susan Leigh Star explore a variety of cases where classificatory systems (including labels of categories and the standards used to constitute them) create divisions where some are left inside a system while others are excluded (1999). Inclusion can be for negative things like diseases classified in a clinical manual. However, inclusion in diagnostic categories can also be tied to important resources such as insurance coverage and an overall sense of being seen and heard by professionals and society writ large. Some examples of resources related to being part of included systems of diagnosis are individuals impacted from the Chernobyl Disaster, as described in Life Exposed by Adriana Petryna (2013). In 1986, the Chernobyl nuclear reactor exploded in Ukraine, causing massive environmental damage as well as long-lasting effects on the genetical structure of cells in the human body. Petryna speaks with people who live and work in the area including those who were dispatched to attend to the area after the explosion and how risk was understood and discussed in terms of exposure. Throughout the book, Petryna explores how science and politics informed Soviet response and how “rational-technical” controls of defining risk impacted human lives. Individual and population health (or lack thereof) thus becomes constructed in terms of biological citizenship in post-Soviet Ukraine, linking their bodies and states of illness or wellness to the identities of being Chernobyl survivors in order to receive medical access and social welfare benefits through the state.

Medical anthropology focuses on exploring this nexus of culture and health. For example, medical anthropologist Arthur Kleinman examined cases of neurasthenia in China during the 1970s in Social Origins of Distress and Disease (1986). Kleinman observed symptoms resembling those of depression, as classified in the United States, but the patients identified themselves as experiencing physical dysfunctions of nerves rather than as emotional or psychological problems. Patients also used terms akin to “boredom” and “discomfort” along with physical symptoms such as pain or fatigue rather than common terms that one might find with descriptions of depression in Western contexts. This set a trend in cross-cultural psychology and shaped medical anthropological approaches so that people could understand disease in broader terms than “universal” scientific knowledge based on Western-centric models. Within an emic perspective, traditional Chinese medicine is a logical response for how illness is framed and understood. But from an outsider’s or etic perspective, these beliefs and practices seem alternative or curious. Kleinman showed that cases of neurasthenia, for example, were part of the fallout from the Cultural Revolution and connected the depressive symptoms to broader social context. Other scholars have built on Kleinman’s work over the years. For example, Tanya Luhrmann asserts that the point is not to uncover the mystery of whether Chinese neurasthenia is really the same as American depression. She argues that it is always about a combination of factors like “genetic vulnerability, bodily stress, social milieu, cultural interpretation, family history, and individual temperament” (20) that are always entangled.

More recently, Luhrmann and her colleagues have stressed nuances that can come from multi-sited studies (the U.S., Ghana, and India) that show how psychiatric diagnoses such as schizophrenia can show up differently based on cultural context (Luhrmann et al. 2015). While auditory experiences or hearing voices were similar in terms of the variation of good and bad voices or the range between conversations, whispers, and less distinguishable sounds across all three settings, there were noticeable differences. For example, interviewees in Accra, Ghana and Chennai, India reported that most of their experiences with the voices were positive whereas U.S.-based interviewees did not report a single positive relationship with their voices. The researchers explore and critique several explanations for these differences, ultimately arguing that “the difference seems to be that the Chennai and Accra participants were more comfortable interpreting their voices as relationships and not as the sign of a violated mind. We suspect that the American cultural emphasis on individual autonomy shapes not only a clinical culture in which patients have the right to know, and should, their diagnosis, but a more general cognitive bias that unusual auditory events are symptoms, rather than people or spirits” (Luhrmann et al. 2015, 44).

Defining health and illness is not a clear case of pulling the curtain back on objective facts, diagnoses, and categories but rather, one of situating experiences and knowledge in broader social, economic, political, and cultural contexts. There are stakes for individuals in being seen as normal, included within societal circles but there are also critical stakes for individuals to be seen as “pathological” enough to receive appropriate care, treatment, and associated resources. Furthermore, there are complicating factors when third parties have stakes in the matter; one example lies with major industries such as pharmaceutical corporations opening new markets (or expanding already established markets) for disease management.

Structural Violence, Biopower, and Selfhood

Critical medical anthropology focuses on the idea that human health is profoundly impacted by biosocial and political economic factors such as the effect of social inequality on individual and population health. It blends theory with on-the-ground ethnographic methods to better understand the political economy of health.

The term “structural violence” is often credited to Johan Galtung (1969) who described how social institutions and structures impact health. In public health, populations rather than individuals are the unit of focus and the disparities between one subpopulation and another can often be analyzed to surface structural roots to those differences. While health disparities name differences, inequities name differences based on structural analyses linked to violence on the bodies and the body politic. Economic and social deprivation is one such factor and exemplified in redlining policies that segregated Black Americans and prevented them from purchasing property. Segregation into areas where there is less availability of supermarkets and healthy food options contribute to higher rates of hypertension, obesity, and diabetes over time. A second factor is toxic substances and hazardous conditions. If data based on housing discrimination, food deserts, and pollution such as smog or soil-lead contamination are mapped as layers in the same region, it becomes clear how structural violence over time accumulates in the body and manifests in the form of health inequities. In the same neighborhoods also lies increased exposure to targeted marketing of commodities such as liquor and tobacco products and inadequate access to health care. One factor that counters these is increased resistance via the presence of community resources that support dignity and mobilize for action against racism (2001).

Some of the seemingly unrelated factors “outside” of health that have been shown to deeply impact health and health inequities are called social determinants of health. The World Health Organization (WHO) describes social determinants of health as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (2020). Social determinants of health can range from economic policies and social norms to built environment and urban planning. These systemic inequities then shape the availability of care for a wide variety of issue from hearing (Planey 2019) and dental health (Raskin 2015) to cancer (Doll et al. 2017). Factors such as community resources and mobilization as well as strengthening existing social connections can bolster health outcomes as well as underscore the existing assets within communities, resisting deficit-based narratives. In social relationships and community mobilization toward a greater purpose that tackles systemic issues, individuals and groups find ways of tapping into health and well-being.

Today’s health technologies can play out via vaccine development as well as through protocols and policies. Anthropological analysis can shine a light on how the development of medical technologies has impacted how people view themselves and manage their health. One example is in the visualization of the mind and to some extent, the self, as brain imaging technologies became more accessible. In Picturing Personhood, Joe Dumit (2004) explores the impact of positron emission tomography or PET scans on individual identity and public dialogue. By analyzing transcripts from interviews as well as fieldnotes from participant observation and media analysis, Dumit shows how people grapple with the nature of images and whether such visualizations provide scientific evidence of brain disease, psychiatric disorders, criminality, or differences in thinking across genders. The development of new tools and their availability through supporting structures such as insurance policies or reimbursement models for health care management informs how technologies shape private and public imaginaries related to health and wellbeing.

Other examples highlight how technologies such as in vitro fertilization and organ transplantation have transformed and shaped identity and personhood as well as health for both oneself and one’s kin. By comparing the evolution of discourse around brain death in North America and Japan, Margaret Lock (2001) shows how brain death is not a standard, universally objective state but one that is shaped by different local histories and cultural formations. For example, in Japan, brain death became legally recognized as recently as 1997. Because of its recent legal acknowledgement, the ability to support organ transplantation was restricted in Japan. Life, death, and the processes by which life might be conferred to others via transplantation are defined at the intersection of the technology to be able to conduct the transplant, the legal rulings and policy support to define biological categories in ways that shape rights and the broader cultural milieu in which these technologies and legal-political narratives are shaped.

Useful concepts in understanding how technologies have impacted selfhood and social relations include biosociality and biological citizenship. Paul Rabinow (1996) explains how biosociality occurs when people diagnosed with a specific illness or disease begin to form their own sense of self and identity around that information. In turn, they may then build kin relationships or community with others who have built a similar sense of self-identity. Genetic predispositions or cancer diagnoses are examples of health and disease-oriented formations of individual and collective subjectivities. Biological citizenship to citizenship projects that link people to beliefs about biological existence as individuals, families, communities, populations, races, and species (Rose and Novas 2005).

Collective identity, when grounded in nuanced perspectives rather than essentializing narratives such as those around race, can provide the space for challenging technologies and biocitizenship projects. Recall our earlier discussion of Michael Montoya’s work on diabetes and how systems collect and interpret biological material, often at the expense of people to whom that material belongs (2011). Another example is in genomic projects in North America, population categories are inconsistently defined. Kim Tallbear (2014) describes how scientists might draw blood from people who are enrolled members of the Turtle Mountain Band of Chippewa Indians. The blood sample and its genetic meaning then gets labeled with this group name. Other scientists who are working collaboratively with this team might then obtain samples from the same region under the label “Sioux” but through multiple reservations and facilities. In this case, federally recognized tribal boundaries as well as ethnic designations that include multiple tribes collide in the sampling practices of genomic projects and their associated biomedical technologies (Geddes 2014).

In addition to discussions focused on biomedical  technologies, public health responses beckon broader conversations about containment strategies as different cities, states, and countries take diverse approaches in the absence of federal directives. In 2005, the US Department of Health and Human Services released a pandemic preparedness plan (HSC 2005). Pandemics themselves had been recorded in world history, including the 1918 flu pandemic which was a deadly H1N1 virus that impacted a third of the world’s population at the time. However, in the 21^st century, the world population was not only larger but also more closely interconnected through broader and faster global flows of travel and migration, as well as supply chains that impact distribution of equipment and products that might be integral to test availability, vaccine production, and medical devices. Globalization had made possible dialogues about contrasting national approaches to diseases that impacted different cultures and peoples, taking shape across the years, and heightening in focus beginning in the 1980s during the AIDS epidemic, and later followed by outbreaks of Ebola, West Nile, and drug resistant tuberculosis. Along with the flow of people, things and ideas, contemporary trends such as urbanization and population density along with environmental disturbances and the deterioration of public health infrastructures all influenced the need to understand health and wellbeing beyond highly localized approaches.

In examining the combination of actors, institutions, and devices that come together to address pandemic preparedness, Andrew Lakoff shows how stakeholders galvanize around a shared interest even if tensions continue to exist in ways that are not always aligned (2017). Examples of stakeholders include influenza specialists, government funding agencies, virology laboratories, and disease detection networks; nonhuman factors include protocols, biosafety devices, and structures such as institutional review boards.

Building off his earlier work examining “The Generic Biothreat” (2008) where he delineates a shift from focus on epidemic or pandemic prevention to planning and preparedness, Lakoff (2015) explores in depth the ways in which global health experts manage the future wellbeing of populations through two key strategies: actuarial and sentinel. He closely examines the controversies and debates that erupted over vaccine development in Europe for H1N1 or the avian-like swine influenza. Actuarial strategies are grounded in the idea that disease can be mapped over time and across populations in order to address the risk of a pandemic. Actuarial approaches depend on the presence of comparable historic data to build models that can estimate future probabilities. In contrast, sentinel approaches treat pandemics as unprecedented and by that very definition, something that cannot be mapped or predicted. One can increase preparedness but never fully prevent or estimate how a pandemic will unfold. Instead, groups can prepare more effectively by building capabilities and capacities to respond quickly to unprecedented and unpredictable events with full acknowledgement that knowledge to create models for response will always be incomplete. The two definitions and approaches conflict with one another but usually appear together as tensions.

Lakoff and scholars in the field of public health management often build upon theoretical constructs like biopolitics and biopower, as articulated by Michel Foucault in the 1970s. Foucault explained that biopolitics was a means of understanding the strategies and mechanisms that were utilized to manage life processes like health and wellbeing. He writes:

What we are dealing with in this new technology of power is not exactly society (or at least not the social body, as defined by the jurists), nor is it the individual body. It is a new body, a multiple body, a body with so many heads that, while they might not be infinite in number, cannot necessarily be counted. Biopolitics deals with the population, with the population as a political problem, as a problem that is at once scientific and political, as a biological problem and as power’s problems (Foucault 1976, 245).

These strategies were further heightened by the increasing availability of public data about populations and population health characteristics which allow for disease management to fall under biopolitical apparatuses.

In 2015, members of the United Nations adopted Sustainable Development Goals (SDGs) as a collective call to action to address and end poverty and protect the planet. Goals are aimed to make advances and to monitor progress by 2030. There are 17 SDGs and they overlap and intersect with each other because it is acknowledged that they are interrelated. The 17 goals are:

• No poverty
• Zero hunger
• Good health and well-being
• Quality education
• Gender equality
• Clean water and sanitation
• Affordable and clean energy
• Decent work and economic growth
• Industry, Innovation and Infrastructure
• Reduced Inequalities
• Sustainable Cities and Communities
• Responsible Consumption and Production
• Climate action
• Life below water
• Life on land
• Peace, justice and strong institutions
• Partnerships for the goals (UN 2015).

The UN’s Development Programme is supporting implementation of the goals in 170 countries and territories. This effort requires partnership development not only between the UN and the governments of these countries but also involvement and leadership from the private sector, civil society (such as nongovernmental organizations) and individual citizens.

While the intentions of the SDGs are straightforward at first glance, there are some critiques of initiatives and projects grounded in development frameworks. For some, historical roots of “development” programs call up colonial enterprises and the notion of non-Western cultures as being in need of civilizing. These colonial endeavors have also simultaneously exploited local and natural resources while mapping onto local cultures external definitions of modernity, economic success, and improved education and health (Liverman 2018). Prior to the 2015 SDGs, the UN released a Millennium Declaration in 2000 listing . Liverman writes, “While the goals are associated with some improvements in incomes, health, and access to food and water, they are also flawed in the selection of targets, the accuracy of measurement, and the aggregation of data and classification of countries. The MDGs significantly reoriented the activities and discourses of donors, nongovernmental organizations, and developing countries” (169). The MDGs and by extension the SDGs can fall under neoliberal critiques where measurement through quantitative outcomes and market driven solutions are prized as means of achieving progress. “This biopolitics defines people as poor, women, slum dwellers, students, or workers—where progress is defined through higher incomes, urban services, education level, or equity—and not through the multiple identities of individuals, their collective actions, or the many other aspects of well-being and rights” (Liverman 2018, 172). Funding and policy support often follow the priorities identified through the goals, leading to focused attention and resources on some areas of investment over others.

While this chapter has focused a great deal on definitions of health and well-being and the various political, economic, and social forces that can impact experiences of health and illness, it is important to also note that equally as important are the bureaucracies and policies set up in the name of supporting population health goals. For example, in Chile, Universal Health Coverage or UHC became a priority not only locally but as part of the global health agenda as a result of its integration into the SDGs. Ethnography and anthropological perspectives can help elucidate how “coverage” itself takes on different meanings depending on local context. Even with the promise of solutions like UHC, researchers have shown how inequities can still exist for those experiencing health challenges such as diabetes (González-Agüero et al. 2019). A growing body of research also emphasizes the importance of understanding the social valence of health insurance (Dao and Mulligan 2015).

Changing Demographics

Demographic transitions refer to periods when populations grow, shrink, and reach stabilized numbers. Here, our earlier discussion of biopower is expounded upon in Susan Greenhalgh’s work with Edwin A Winckler, Governing China’s Population: From Leninist to Neoliberal Biopolitics (2005) who outline how China’s policies impacted demographic shifts. Tracing these shifts, perhaps most exemplified in the one-child policy, demonstrates how women become charged with the responsibility of reducing the fertility rate and supporting a “quality” single child that will add to the future success of the family and nation-state.

Declining fertility rates or concerns about the replacement rate also create several pressures related to sustaining the nation’s population and multiple strategies or campaigns might be deployed at the same time. For example, a country might encourage childbirth through policies that address concerns revolving around economic rationale (e.g., making early childhood education free or more accessible, making sure that women are not penalized whether overtly or indirectly via limited career opportunities should they choose to have children, etc.). Another strategy could include changes to immigration policies to encourage migration to the country, supplementing the “younger” end of the demographic spectrum through immigrants and new citizens (i.e., both adults in the middle of the spectrum as well as adults who might be more inclined have children).

Denmark also experienced a change in fertility rates and chose to pursue creative avenues of promoting the choice to have children as part of good citizenship. With growing concerns about maintaining stable population numbers due to a declining birth rate, Danish media and travel joined forces to come up with incentives that might encourage couples to get pregnant. In 2015, a travel company called Spies Rejser began offering gift packages that included a family holiday and three years of baby supplies to anyone who could prove that they conceived during travel booked through their agency. It is interesting to note that the decline in birth rate was observed in a country already known for more comprehensive policies that support universal access to early education as well as more integrate health and social service policies. For higher rates of taxation, families in Denmark have access to public childcare and universal healthcare. Even with some of these national infrastructures in place, couples were not conceiving so the private sector vis a vis travel stepped in to provide additional incentives. Nongovernmental organizations also stepped in, including one nonprofit adding benefits to pregnancy in their sex education curriculum for schools (along with existing session on prevention). Another campaign called “Do it for Denmark” used a series of advertisements to encourage conception and childbirth. The campaign received praise for its tongue-in-cheek approach as well as criticism for age and gender stereotypes along with heteronormative tones (Gonzalez and Malone 2019).

Another take on the discourse of fertility rates includes a critical reflection on how low birth rate itself is shaped in “pathological” terms. In their study of the Italian nation state and its reaction to declining birth rates, Elizabeth Krause and Milena Marchesi show how policies encourage certain residents to embrace reproduction or pronatalism while others are discouraged. The fault lines often fall in between couples deemed to be desirable citizens of the nation-state versus others who suffer from social and political inequities related to racism and xenophobia. Declining birth rates are construed as a “demographic emergency” and policies that range from monetary baby “bonuses” (i.e., financial incentives) to laws restricting assisted reproduction converge to form a social and political discourse that normalizes what good fertility looks like and what dangerous or pathological fertility looks like. Krause and Marchesi refer to these discursive plays as “social Viagra” that is aimed to stimulate norms about family and a healthy population that is part of an ostensibly thriving nation-state.

The world’s population is also growing older, in part due to medical technologies and advancements that allow for longer lifespans. Additionally, agricultural and food advances along with medical treatment and access have reduced infant and child mortality rates. Meanwhile in some countries, the average age of the population is shifting older as people live longer and others choose to limit or forego having children.

The aging population around the world brings up social gerontological questions such as “How to finance pensions? How to improve the quality of life and well-being of older people? How to limit their feeling of loneliness? How to transform the negative images?” (Macia, Chevé, and Montepare 2019, 1). Building on Foucault’s concept of biopower, Macia, Chevé, and Montepare argue that 18th century medicine in France led to increasing medical progress via political authority over medicine and the privilege, respect, and resources afforded to medical practitioners and researchers. Advancements such as the smallpox vaccine allow for decline in mortality rates. Importantly, the authors point out that biopower is not only seen in governmental or political phenomena but also part of an internalized sense of disciplining the body which shapes how people think about their own personal responsibility for preserving their health and the health of their family members. This has shaped both the demographics of populations and the discourse and discipline around what it means to maintain health to “successfully” age. Across many societies around the world, this notion of successful aging may be seen “as a construction of biopolitics which encourages social and physical activities among older adults so that they remain ‘useful’ and are not a ‘burden’ for society. Of course, this biopolitics rationalization of existence may be internalized and older people themselves come to see successful aging as active aging” (Macia, Chevé, and Montepare 2019, 6).

Experiences with aging also vary based on local context. For example, 24% of Japanese women in their study did not note the end of menstruation as part of menopause, stating that they had no sign of kônenki even after not menstruating for a year. In doing so, they did not distinguish their aging process from men in terms of ceasing to menstruate. In fact, the dominant discourse in Japan links typical menopausal symptoms to the “destabilization of the autonomic nervous system” over changing estrogen levels (Lock and Kaufert 2001, 502).

In the U.S., Sarah Lamb (2019) describes how older white Americans across social classes speak about “healthy” or “successful” aging as a means of avoiding the negative elements associated with aging. Lamb emphasizes how cultural ideologies as well as medical interventions and individual experiences come together to stigmatize getting older. The ability to ward off oldness in these stigmatized or negative terms are often contingent on being able-bodied and among higher socioeconomic classes.

Across the globe, in Denmark, Henrik Hvenegaard Mikkelsen, Nete Schwennesen, and Aske Juul Lassen have traced the seismic shift from a more paternalistic nation-state that saw itself as responsible for caring for older citizens to today’s “active aging” policies that focuses on empowering discourse around successful and healthy aging. For example, initiatives reanimate or activate older systems through engagement in civil society as volunteer workforces. Programs for older patients such as a choir or bike trips are situated as not only methods of supporting successful aging but also thinking about “energy” such that active aging converges with new forms of government that promote active citizenship and in turn, activated citizens become energizing forces for the welfare state (Mikkelsen et al. 2019).

Conclusion

Successfully aging is just one of many elements that influence how cultures define what it looks like to achieve and maintain health and well-being across the lifespan. Through different seasons of life, human beings navigate a myriad of factors that shape their beliefs and practices both as individuals with distinct needs and as groups swimming through, with, and against the tides of historical, political, economic, social, and cultural contexts.