Society, culture and the social construction of health

The first formal definition of culture in the modern sense was given by the British anthropologist Edward Burnett Tylor in 1871: that complex whole which includes knowledge, belief, art, morals, law, custom and any other capabilities acquired by man as a member of society. Two words in that sentence carry the whole theory — acquired and member. Culture is not carried in the blood; it is acquired, and it is acquired by belonging. The process has a name: enculturation, the largely unconscious learning of one’s own culture from birth, through language, feeding, toilet training, naming, greeting, dress and the sanctions that follow a mistake. Enculturation is not the same as acculturation, which describes what happens when two cultural groups live in sustained contact and both change — usually unequally, with the less powerful group adopting more of the dominant group’s practices than the reverse, and with the second generation often carrying the strain. Because enculturation is invisible from inside, every group tends to judge others by its own standards, a habit the sociologist William Graham Sumner named ethnocentrism in 1906. The corrective is cultural relativism, developed by Franz Boas and his students: the claim that a practice must be understood in terms of the meanings of the people who hold it, and not measured against the observer’s scale. Clifford Geertz later described cultures as webs of significance that people themselves have spun, and argued that the task is not to catalogue customs but to read their meaning. Ruth Benedict had already shown, in Patterns of Culture (1934), that whole societies can be organised around different values and produce different personalities without any of them being defective. Nursing needs relativism as a method and must also know its limit: understanding a practice is not the same as approving it. When a practice causes serious harm, such as female genital cutting or the withholding of food from a sick child on a healer’s instruction, the nurse still has a duty to protect, and the professional answer is to understand the belief, work with trusted insiders, and act. Cultural universals exist alongside these variations — every society has language, kinship, some notion of the sacred, some treatment of the dead and some recognised role of the healer — which is why nursing can learn general principles while still asking each family what its own customs require.

The strongest evidence that a definition has power comes from the study of labelling. Howard Becker argued in Outsiders (1963) that deviance is not a quality of the act but a consequence of the rules and sanctions that others apply to it; the crucial actors are not only those who break a rule but the moral entrepreneurs who make it, and the same act can be a crime, a sin or a symptom depending on who is doing the defining. Edwin Lemert had already separated primary deviance, the original act, from secondary deviance, the identity a person builds in response to being caught and treated as deviant: the reaction, not the act, produces the lasting career. Erving Goffman, in Stigma (1963), described the result as a spoiled identity and made two distinctions nursing uses daily — the discredited, whose difference is already visible, and the discreditable, whose difference can still be concealed, and who therefore manages information, weighs disclosure, and may pass as ordinary or cover the mark.

He also adopted and popularised the term courtesy stigma — introduced by Elaine and John Cumming in 1957 — the courtesy by which relatives and carers are contaminated by association; in many families the diagnosis of a member reduces the marriage prospects of a sister. The psychiatrist Thomas Szasz argued in The Myth of Mental Illness (1961) that much of what is called mental illness is a label for problems in living, and in 1973 the American Psychiatric Association removed homosexuality from its diagnostic manual, which showed that a category written by a committee can also be unwritten by one. The classic demonstration of how hard labels are to escape came from David Rosenhan, whose 1973 study sent eight mentally healthy people into psychiatric hospitals; all were admitted, none was detected by the staff, and their ordinary behaviour — note-taking, waiting, pacing — was recorded as symptoms of the disorder already written in their files.

HIV provides the epidemiological version of the same mechanism. Stigma and the fear of disclosure are recognised barriers at every step of the care cascade: people postpone testing, collect treatment far from home, miss appointments and abandon care, so a condition that is medically treatable continues to kill for social reasons. The nursing consequences are specific and testable. Words written in a file follow a patient through every future admission, so describe behaviour and record facts rather than character: “arrived at 21:40, unaccompanied” is a fact, “uncooperative” is a label. Protect confidentiality actively — a private space for a conversation, no names at the door, no visible drug packaging — because for a discreditable patient confidentiality is not a courtesy but the condition for returning. And separate the person from the category in speech as well as in writing, since a label spoken aloud in a crowded corridor can undo months of adherence.

Some of the clearest cases of social construction are numerical. The body mass index was invented by the Belgian statistician Adolphe Quetelet in the 1830s and 1840s, not as a clinical instrument but as a way of describing the average man of a population; the American physiologist Ancel Keys renamed it the body mass index only in 1972, and it entered international use as a screening measure for groups rather than a diagnosis for individuals. A limit is therefore always a decision, and a decision has an author and a date. In 1998 the United States National Institutes of Health lowered the boundary that defined overweight from a body mass index of about 27.8 for men and 27.3 for women to a single figure of 25, reclassifying millions of people overnight without any of them changing weight. In 2004 a WHO expert consultation recommended lower action points, 23 and 27.5, for populations of Asian descent, because cardiometabolic risk appears at a lower body mass index in those groups — a recognition that even a threshold carries assumptions about whose bodies were measured.

Menopause followed a comparable path. The gynaecologist Robert Wilson’s book Feminine Forever (1966) presented menopause as a deficiency disease to be corrected with oestrogen, and prescribing expanded for decades until 2002, when the Women’s Health Initiative halted the combined oestrogen-plus-progestin arm of its trial because the risks outweighed the benefits; the definition of menopause and the standard prescription changed within a year. In each case the biological process was unchanged and the medical verdict moved. This is the territory Ivan Illich attacked in Medical Nemesis (1975) as iatrogenic — medicine producing harm by expanding its own jurisdiction — and that Irving Zola described in 1972 as medicine functioning as an institution of social control. The counter-process is demedicalisation, and homosexuality’s removal from the diagnostic manual in 1973 is its standard example. None of this makes a diagnosis unreal. W. I. Thomas stated the rule in 1928: if people define a situation as real, it is real in its consequences. Robert Merton developed the same insight in 1948 as the self-fulfilling prophecy, and Bruce Link and Jo Phelan argued in 1995 that social conditions such as stigma and socioeconomic position are fundamental causes of disease because they keep producing new pathways to illness even when the old ones are blocked. The physiological route is now well described: chronic exposure to discrimination and threat keeps the stress response switched on, raising cortisol and blood pressure, and the cumulative wear is called allostatic load. For nursing, the practical discipline is to know where a number comes from and what it does. Ask which authority set the limit, when, and for which population; ask what happens to this patient if the label is entered in her file, who will see it, and what she may be refused because of it; and use the label as one description among several rather than as the whole identity of the person in front of you.