Toward a Critical Phenomenology of Health

Abstract

Phenomenologies of health remain relatively infrequent compared to phenomenologies of illness. This paper addresses this lack by first summarizing some key elements of phenomenologies of health. First, health typically resides in the background of our experience. Second, health requires a creative, adaptive capacity to life’s variations. The paper then explores prescriptive critical phenomenology of health. It highlights key elements of treatment to produce health that avoid a reductive medicalized approach. The paper examines the social and political determinants of health as key elements of a critical approach to health. Finally, it argues for support of public health as essential to questions of health to counteract the contemporary view of health as solely a personal, rather than contextual, matter.

1. Introduction

Phenomenological accounts of health aid in working against naïve views of health as solely a matter of good biological functioning where truth is held by medical experts alone. A critical phenomenology of health and illness critiques medicalization by examining the lived body in its temporal situation—past, present, and future—as well as in its social and political context. As Merleau-Ponty says, “Man is a historical idea, not a natural species.” [1] (p. 174). Phenomenological accounts do engage and expand upon medical accounts of illness, but they are not co-extensive with medical models. Irving Zola’s [2,3] concept of “medicalization” is a response to the way in which 20th century-medical practice was seen as the primary arbiter of bodily differences as being fundamentally medical issues. For example, mental illness as not a personal moral defect, but as a medical one. Medicalization also signifies the idea that where the truth of the body lies is in the hands of medical experts since medical models are purported to be “objective.” Certainly, evidence-based medicine, where the body is taken as an object to be diagnosed and treated in parts, has produced great results in understanding and ameliorating illnesses. But medicalization has encouraged the view that there are no subjective or contextual aspects of health; the body as an object is the exclusive source of health or illness and thus the only point of inquiry. We find a parallel assumption in most naïve accounts; the idea of health and illness is assumed to be about “natural” parts of us, something that can be understood as a discrete thing that one can objectively know only through external medical evaluation.

In distinction from a medicalized model, I explore below a phenomenological non-naturalizing approach to health. First, I address how phenomenologies of health ground their discussions in describing the unthematic backgrounded nature of health. A phenomenology of health deviates from numerous phenomenologies of illness, as health does not present a discrete state of experience that can be addressed. Health operates as a condition for other states rather than a state-in-itself. Second, the paper addresses how health also needs an active and creative element. The paper will argue that rigidity to a habitual way of being means the individual cannot weather change as the most constant part of life. Third, the paper explores how a phenomenology of health can influence individual treatment. Fourth, I highlight the social determinants of health and tie critical phenomenological accounts to public health. In conclusion, I discuss how contemporary biomedicalization encourages a view of health as an individual product that obscures the environmental, social, and political factors in health. I propose that critical phenomenologies of health should ally with public health calls to focus on policy rather than ameliorating individual health.

2. Health as Equilibrium, Harmony, Homelikeness

It is far easier to know if one is ill than if one is healthy. One may feel good, even joyous, but is this health? Or is health simply the absence of feeling poorly, a state that may or may not have a distinct feeling state of pleasure? On the contrary, illness is a problem, a call to attend to the body, an intensification of the sense of being in-a-body: being trapped within a body. In English, we say “I have a cold; I have cancer; I have a broken foot”—where the illness is separate from us, an object from which we can separate ourselves. Health, on the other hand, is inextricable from us; we cannot say “I have a wellness; I have a health.” In this section, I examine the theme of health as a background that only becomes explicit when it is absent.

Maurice Merleau-Ponty writes that our consciousness does not identify itself with an illness. We always feel beyond our sickness [1] (pp. 458–459). Given illness is seen as separate, as a problem, it is no surprise that the problem of illness has received more attention in phenomenological accounts than health or wellness (Leder [4,5], Aho & Aho [6], Carel [7,8,9], Toombs [10] Zaner [11] Svenaeus [12,13,14,15], Ratcliffe [16,17,18], Slatman [19,20], Welsh [21,22]). One of the most central claims in phenomenologies of illness is that health is known not positively as a discernable experiential state—like happiness or joy—but rather as an absence. We recognize health best when it is lost and we want to recover it. In this sense, health is an “enigma” as Hans-Georg Gadamer explores in his slim book, The Enigma of Health. Health is a background embodied state, present but typically hidden from conscious life. The language of equilibrium, harmony, and heimlichkeit (homelikeness) are ways phenomenologists have tried to capture the elusive experience of health.

Illness illuminates health by relief; illness shines a light on what is lost: the grounding nature of health. Gadamer argues that a key feature of health is a sense of being removed, pushed out, or fallen from one’s previous sense of well-being. “The sick individual has already fallen out of their normal place in life.” [23] (p. 42). The idea of health as hidden, or situated in the background, views health as what allows other freely chosen investments to dominate one’s attention. For Gadamer, the idea of equilibrium captures what health provides as the “condition of not noticing, not being unhindered, of being ready and open to everything.” [23] (p. 73). Maurice Merleau-Ponty likewise underlines the idea that in normal, healthy embodiment, one extends naturally into the world through an “intentional arc” that creates a unity of actions, consciousness, and senses. This directedness toward the world in which our body facilitates engagement goes “limp” in illness, where we are required to turn back to the body as a hindrance, not as the place from which we live engaged with others [1] (p. 137).

Contemporary theorists have continued to emphasize the sense of loss and lack in their depictions of illness. Havi Carel writes that illness leaves an “overall sense of purposeful activity as lost.” [8] (p. 349). Health is the ability to extend forward into the world, not just in a physical sense, but in a virtual sense where one intuitively imagines being able to act in the future as one can act today. Carel also discusses how health is constituted by the experience of the lived and biological body as harmonious: “In health, the two aspects of the body cohere, responding in harmony to a normal range of experiences. In illness, the biological body comes to the fore, as it ceases to cooperate with the ill person’s desires.” [8] (p. 352). My body becomes abnormal to me when I must attend to it even when I do not want to, when my desire to be in the world is interrupted by a need to turn back to myself.

Don Landes [24] argues that in illness, “the trajectory of the person’s life is at risk of being simply cut off, and the meaningful projects they have been engaging with are at risk of being left hanging.” (p. 278) If I can get to work and go through my day, a work that I find meaningful, but I am in a fog of pain and discomfort, the nature of these activities has become unmoored. I am anxious about how long I can continue; I am unable to extend easily into humor or pleasure at opportune moments. I am focused solely on essential tasks. The normal habitual background shape of my experience is lost. Part of the background that constitutes health is an implicit connection to a meaningful world of possibilities that then makes particular investments and actions possible. Even if in an illness I can perform some of the tasks required by my work, if the illness has no likely end, an unclear trajectory, or signals the beginning of future illnesses, the valence of my work will be thrown into the air. Work is often meaningful for practical reasons—I need to pay for my food—as well as personal reasons—I find my work valuable; my work gives me pleasure. Such meanings are tied not just to the capacity to do work at any particular moment but to the idea that when working, this work and other kinds of work will be possible in the future. Illness throws us out of balance and requires us to draw attention to what in health is simply part of being.

Fredrik Svenaeus [12,13,14,15] has one of the most complete contemporary phenomenological descriptions of illness and health. Drawing upon Heidegger, Svenaeus underlines how the meaning of an experience is not simply about willed projects, investments, or plans, but about one’s attunement [12] (p. 60). Certainly, an illness can make one unable to achieve a certain task or life goal, but a long-term illness does not just interrupt particular investments; it reshapes one’s general experience by limiting the possibilities for other kinds of meaningful experience. As noted above, some illnesses do not limit the possibility of performing certain tasks one could do in health, but illness shapes the texture of such actions. Illness creates a mood where not just certain actions might be inhibited or impossible, but one’s intuitive sense of possibility can be damaged, making one hesitant about any kind of future investments. Svenaeus uses the concept of unheimlichkeit—unhomelikeness—to explicate the lack or loss in illness described above. Phenomenologies of illness expand upon the idea of meaning in health to underline how a meaning pattern is not just a matter of one’s intended ongoing and future projects but also an affective understanding that shapes a healthy bodily equilibrium.

Svenaeus argues that health is the sense that one’s place in the world is sensible, calling health heimlichkeit—homelikeness [12] (p. 55). In a home, we move freely, secure in our safety. We have a sense of belonging. A home provides a place from which we can imagine new possibilities, even ones that contain risk, since we can recover and retreat if necessary. Any life has frustrations, hindered plans, tragedies, and random difficulties, but as long as we have a sense that we have somewhere where we can safely recuperate, we can be healthy. When our bodies are not such a home, we are even more vulnerable to life’s fluctuations. In some sense, homelikeness is when we are made somewhat oblivious to our inherent human fragility. Health is the “being at home that keeps the not being at home in the world from becoming apparent.” [12] (p. 71). In health, we can easily move into the world and move back out of it when needed. Not only can our bodies become ill or injured, but the world can violently intervene and make our sense of security shatter. In such a way, while homelikeness constitutes health, illness can be part of what reveals the nature of our existence and can, like anxiety, be a place from which to reflect philosophically [9]. This is not to say that illness necessarily provides a special insight that health cannot, but that the security offered by health can obscure the ways in which any home is open to destruction.

The idea of homelikeness or equilibrium may not initially seem to have much to do with habit, but a habitual manner of living in the world is part of the background of health that is disrupted in illness. Phenomenology often explores habits when considering kinesthetic learning, where a skill can move from deliberate to habitual. These kinds of examples consider how awkward and deliberate bodily movements that require attention eventually move toward the background so the activity itself can become front and center. A good pianist no longer needs to find the keys when reading a piano song. A skilled tennis player raises a racket to respond without thought to a serve. Illness also disturbs bodily habits, often ones that were learned long ago and can seem part of an instinctive, natural way of being. The capacity to sit down at a piano and play or grasp a tennis racket is based in primary habits of motor coordination. Walking, speaking, socializing, and having the basic wherewithal to attend to work all are based upon our developmentally acquired capacities. Even something as natural for many of us as putting a cup to our mouths to drink is for a toddler a very messily acquired achievement. The changing nature of an ill or injured body presents embodied situations where old, seemingly inherent, habits become challenging.

I highlighted above how in health, one has a sense of ease with one’s body and an implicit confidence in one’s future bodily states. When ill, not only am I suffering, but I am unclear about the future. These unthematic bodily habits are part of the background in health that is lost in illness. However, when habits are rigid, when they refuse to accept the normal fluctuations of bodily change and environmental disruption, then one also is easily thrown out of health. The fact that the harmony or equilibrium in health must be flexible to the changing world and changing body will be detailed below.

3. Creative and Normative Adaptation

Frustration, discomfort, and even suffering do not necessarily mean one is ill. Health must include a capacity to endure, respond, and adapt to both everyday changes as well as changes due to aging and minor injuries. The idea of a stable background from which one lives in the world does not necessarily exclude pathological or ill styles of embodiment. The case of Schneider in the work of Goldstein and Gelb and then integrated famously in phenomenology with Merleau-Ponty’s work highlights the view that normal embodiment and ill or pathological embodiment are not, to quote Jenny Slatman’s work on this question, fundamentally different in all respects. Slatman observes, “Pathology and normality are different modalities of the same underlying phenomenon.” [20] (p. 22). Sara Heinämaa & Joona Taipale [25] note that Husserl’s account of normality includes coherence. They suggest that coherence and order can be achieved in a variety of states. One can be clinically ill and still have a coherent, if not effective, manner in which one has structured one’s world. Both ill and healthy modes of embodiment are responses to one’s situation wherein one can find patterns of sensibility. What distinguishes healthy embodiment is not just having a habitual backgrounded world from which one can extend into the world, since this is not always absent in pathological embodiment; rather, it is the capacity for plasticity and creativity to break habitual modes of embodiment.

Merleau-Ponty’s work on Schneider sees his pathology not as a collection of relatively independent disorders that could each be named. Rather, Schneider has a holistic disorder. Schneider’s loss is that of a reduced capacity to interact in varied ways with his situation. Kurt Goldstein [26], from whom Merleau-Ponty drew much inspiration, as well as who provided, with Adhémar Gelb, the original account of Schneider, writes that in order for the physician to treat the patient, the patient’s whole being must be taken into account when it comes to brain injuries or diseases. For Goldstein [26], what is normal, qua healthy, is an ordered manner of acting in the world that preserves freedom in relation to one’s bodily being and one’s environment. His idea of pathological embodiment as disordered does not mean that pathology always indicates incoherence, but instead pathological embodiment can indicate a coherent but fixed pattern of behavior where the ill individual is in bondage to their pathology.

Phenomenological accounts share this idea that coherence and order are two manners of being in the world seen in both healthy and many pathological ways of being. Goldstein’s whole organism approach details the attempt to capture the general structure of an illness and how individuals organize their worlds. Thus, the above definition of health as a background sense of meaning from which one pursues one’s projects in the world would fit many pathological manners of being insofar as they provide a stable situation from which a regular order between action and world can exist. Goldstein, Merleau-Ponty, and contemporary phenomenological accounts of illness share the view that often illnesses have their own shape and sense, even if this shape is shot through with suffering.

What one must add to the idea of a meaningful background in health is adaptivity and creativity in relationship to both one’s bodily being and one’s environment, which is the critical normative feature of health in phenomenological accounts. In The Structure of Behavior, Merleau-Ponty discusses this idea of how one’s mode of being does not just tend toward an equilibrium, or homeostasis, but is anticipatory and adaptive. We can determine particular vital goals in humans where we can draw a direct connection between the action and some physical need: we seek food when we are hungry. Yet, human action is also virtual, possible, and indefinite. The key feature of this capacity to be open to the possible is the ability to direct oneself toward some action, idea, or attunement which is not immediately demanded by the situation. “These acts of the human dialectic all reveal the same essence: the capacity of orientating oneself in relation to the possible, the mediate, and not in relation to a limited milieu…” [27] (pp. 175–176). The “dialectic” is not just the human capacity to respond to the environment, but to consider an alternative possibility to the immediate lived situation. Jennifer Bullington [28] draws inspiration from this account in her defense of the allostatic model as presenting a better understanding of health than the homeostatic model. Unlike homeostasis, in allostatic accounts, there is no “normal” value or state that does not relate to a behavioral context [28] (p. 84). In allostasis, “The autonomic nerve system, the hypothalamic-pituitary-adrenal axis, and the cardiovascular, metabolic and immune systems all participate in our constant adaptation to the environment.” [28] (p. 83). In such a model, a normal range depends upon the demands, situation, and behavior of the individual. Moreover, allostasis can better explain how the body anticipates environmental changes, such as when I am about to engage in a demanding physical activity; my body can override the demand to return to homeostasis in anticipation of preparing for this activity.

Health is thus a dynamic responsiveness to one’s embodied situation, where one can create new meanings and styles given new experiences and new bodily states. “We respond to the world, but we also actively constitute the meaning and significance of the world, on all levels and at all times.” [28] (p. 91). It is difficult in models where health is something “inside” the body to be understood by a test to explain the body’s capacity to learn new skills and respond to new stressors. To constitute new meanings, we must be able to both sediment new structures of meaning into habitual modes of living, such as acquiring a new physical skill or an adaptation to a new bodily limitation. But we must be able to break these habitual modes of living. In this view of health, habitual modes of being are the “norm” of the learned patterns of behavior, habits that are not rigid reflexes but porous to the body and world, thus permitting creative incorporation of change.

Georges Canguilhem’s view of health dovetails with this understanding that we cannot see pathology as some kind of reduction from normal health. He mentions Merleau-Ponty’s The Structure of Behavior as attending to the same central theme in The Normal and the Pathological and elsewhere ([29], (p. 29, [30])). Canguilhem’s view of health is characterized by the capacity to extend oneself out in the world both actually and virtually. In order to do so, one employs norms of behavior—coherent regular forms of action—what phenomenologists would think of as embodied habits. Habits are manners in which we have learned to adapt to the world to create meaningful patterns of behavior in response to how the world calls upon us. These habits provide that bodily part of the background from which I can meaningfully freely engage with the world. In illness, this background ceases its grounding nature, and hence, my extension in the world and into the possible future is disrupted. The challenge is that the world in which I live is highly variable, as is my own bodily state. No habit can guide me successfully through any possible bodily change or situational change. Health incorporates a certain flexibility to the shifting environment. Issues of balance due to changing surfaces, coordination, acceptance of interpersonal disruption, and adjustments to varying degrees of light or heat all need the habit of being open to a changing environment that cannot be predetermined. Canguilhem writes that “Health is a margin of tolerance for the inconsistencies of the environment.” [30] (p. 197). Rigidity to a habit or norm of behavior makes one extremely vulnerable to the environment’s vacillations and the vacillations of one’s own bodily being. The idea of optimality helps explore what health provides the individual in a shifting environment with a shifting bodily state. Heinämaa and Taipale [25] discuss how normality in Husserl relies not just on a coherent background, but also upon the capacity for optimizing experience. A flexibility inherent in one’s habits permits the greater capacity to continue one’s projects when one meets with various kinds of resistance.

However, sometimes one can no longer rely even upon flexibility in habits to meet one’s changing bodily state, one’s environment, or one’s projects. In order to find a new norm that better suits one’s current embodied state, situational changes, or new investments, one must break old patterns of behavior. This requires tolerating incoherence and disorder in order to find a new norm that better fits the situation. Canguilhem writes that one must also be able to break and create new norms, what Goldstein would call freedom, and Merleau-Ponty calls human ambiguity and possibility. Health is, as previously stated, constituted by having habits that allow one to extend out into the world. It accommodates frustrations and the need for small changes. But health also requires being able to shape new norms. Canguilhem writes, “What characterizes health is the possibility of transcending the norm, which defines the momentary normal, the possibility of tolerating infractions on the habitual norm and instituting new norms in new situations.” [30] (pp. 196–197). We can see this both on the bodily level as well as the situational one. For instance, normal aging presents a host of challenges to someone used to a certain physicality. Unless one wants to classify all adult aging as pathological, a person who adapts her physical regime to her body’s changes, say changing a running regime to a walking one, is breaking former norms of embodiment for new styles. Landes returns to Gadamer’s language of equilibrium to argue for a “meta-stable” equilibrium, asserting that “any current equilibrium is in fact a ‘metastable’ equilibrium, meaning that it contains a rich and mostly unpredictable set of potential transformations.” [24] (p. 278). If I cannot envision a new opportunity, if I cannot imagine my way out of a place of suffering, if I cannot move toward a different moment that appears socially, I would find myself only able to engage in repetitive patterns of behavior. One of the challenges of saying what health is is that its primary feature might lie in this capacity for new forms of healthy habits that to us now might appear abnormal.

4. Phenomenological Views on Treatment

This paper has elucidated two major themes in phenomenologies of health. A full prescriptive account of how these themes should influence healthcare is beyond the scope of this paper, but in order to consider the challenges with such an account from a critical phenomenological perspective, we can look to some ways in which these accounts would affect healthcare approaches. Phenomenological accounts of health and illness that center the individual’s experience are valuable to aiding healthcare professionals in understanding how to center individuals’ investments and goals within a medical model. Instead of seeing ideal biometric screenings as the goal of healthcare, the healthcare provider can discuss how whatever available procedures, practices, or products can enable patients to obtain their goals, bringing a greater sense of shared purpose between doctor and patient. Where there are no medical treatments, healthcare professionals could focus on engagement with the world in other ways, highlighting that investing in the world as one can is not extraneous to health but an essential part of it. Phenomenological accounts add an important contribution to medicalized views of health and where the body is an object to optimize without regard to the patient’s individuality.

Beyond the language of consent, a phenomenological approach can encourage reflection on one’s life in general. Instead of simply encouraging patients to give informed consent to treatment, one can focus on the impact of treatment on what is most valuable. Gadamer rejects possible curative practices if they are not tied to some larger sense of creating meaning in one’s life. Good medical practice “does not consist in an increasing concern for every fluctuation in one’s general physical condition or the eager consumption of prophylactic medicines.” [23] (p. 112). While this is but a sketch in his work, one could anticipate his possible critique of the proliferation of pharmaceutical interventions, diets, and lifestyle regimes that demand the individual direct themselves back toward their own body instead of extending out into the world. One can overtreat in the name of “health.” It would potentially be possible to spend any free time bettering one’s diet, exercise routine, and taking any medications that could be seen to improve testable fitness. But this would remove one from meaningful engagement with the world outside one’s body.

For Gadamer, illness is not merely to be treated by a clinical experience but must be seen, like health, as a social experience where treatment requires psychological–moral investments on the part of the patient and doctor. The idea of personal desires, plans, purposes, projects or ambitions is central in phenomenological accounts of health. These are dependent upon the individual’s own proclivities. In this connection, treatment should not exclusively be based on returning individuals to a certain state of “normal” health (such as getting blood pressure correct). Gadamer argues that medical practice should treat what is fitting for the individual depending upon the individual’s life, ambitions, and situation [23] (p. 98). In such a manner, doctors should be careful of standardization in their practice. Landes likewise counsels the doctor to consider the larger good of the individual: “A physician cannot simply make health appear; they must take up nature and prepare for the return of equilibrium, and they must also respond to the life of the person being healed so as to bring about health according to their (perhaps tacit) understanding of the good.” [24] (p. 276). Optimization and creativity in responding to changes cannot be made uniform. Healthcare sciences provide guidelines for what is a good range of blood pressure for people of a certain age but should be understood within the whole of a person’s life. A runner may be far more interested in physical endurance than a writer. Given that optimality is personal, rather than established by what is physically possible for an individual, there are a variety of ways of being healthy instead of a uniform manner of being so [22]. The way in which possibilities shape one’s sense of health helps healthcare providers negotiate frustrations with the limitations of treatment. Exploring how treatment options impact a patient’s sense of possible states as well as current ones can help healthcare providers and patients negotiate the relative importance of treatment options.

The importance of creativity and adaptivity discussed above can provide more agency in the case where medical interventions are not going to produce a return to a previous state. We can still find new styles of living that may ameliorate our condition. In The Healing Body [5], Drew Leder explores different ways individuals can creatively better learn to live with aging and illness. When we age, prior habitual ways of being in the world become awkward or impossible. Instead of seeing this as only a limitation, part of normative health outlined above is this capacity to creatively establish new habitual modes of being. Ideas of “health within illness” are also examples of this normative reshaping of experience [31,32]. A significant part of Leder’s analysis is to indicate how one can attune oneself to one’s current status through exploring alternative ways to frame one’s embodiment. This is not to ignore or gloss over significant loss or suffering but to suggest that we are not always powerless within such situations. Some chronic illnesses or patterns of aging may not be solvable, but they still may be open to creative exploration, which demands we move away from seeing the body as a thing that either can or cannot be fixed.

Another focus that goes beyond medical treatments within a medicalized model is to highlight the larger social concerns that may play the dominant role in the individual’s experience rather than the particular bodily dysfunction. For example, in examining individuals with irritable bowel syndrome [IBS], John Russon and Kristin Jacobson discuss how the individual with IBS’ connection with others is deeply altered. Using the bathroom, a physical space we all require but for many of us remains in the background, now takes up a central place in any plans since it is required at intervals that can be unpredictable. Moreover, having an issue with one’s bowels is deeply shameful [33]. “Said otherwise, the problem a person with IBS faces is not a primarily a problem with the bowels: It is primarily a problem with living a happy and healthy life, with how one has and navigates an interhuman world.” [33] (p. 198). While IBS might seem an obvious bodily issue, rather than perhaps some mental health illnesses that are hard to extricate from their social, cultural, and historical spaces, the meaning of it does not make any sense if one removes it from the interpersonal norms that shape our shared norms of bodily shame. The focus on space, such as “where are the facilities?” and “when would it be socially acceptable to leave?”, cannot be understood with attention to bodily suffering alone.

The above example speaks to our social norms about what a body should do and what it should not—e.g., bodies should not have to use the restroom at unpredictable times. Health is seen as what is the “normal” state and illness and pathology as breaks in such normality. A common challenge for the chronically ill is not only the kinds of limitations the body presents but the limitations of the imagination and empathy of the healthy [7]. Even in situations in which there is no demand upon ill individuals to do something beyond their capacities, the texture and attunement of social interaction tends to invoke assumptions that shape the healthy home world. For example, Matthew Radcliffe underlines how depression “centrally involves the interpersonal and impedes ways of interacting with others that facilitate mutual empathy.” [18] (p. 271). Depressed persons struggle to form worlds where investments and meaning matter, and this impairs empathy since to empathize with another’s worldview demands not just an intellectual acceptance but an emotive interpersonal capacity to imagine one’s attunement to the world in a different manner. However, it is not just that depressed persons struggle to relate to others; healthy persons likewise struggle to empathize with the closure of possibilities in depression. People “who are not depressed will be unable to simulate what it is like to be depressed, given that they cannot shut off their own access to certain kinds of possibility.” [18] (p. 275). It can be tempting to try and encourage a depressed friend to just embrace all that their life offers. When one is healthy, opportunities in life seem obvious and natural. As discussed in the previous section, a key component of health is a plasticity to environments where one can imagine and form a new way of being based on the opportunities that one is afforded. However, this implicit sense of connection with a world can close one off to the world of the ill, where the shape of what is inviting, possible, and desired can be radically different. Health can preclude one from being able to form empathy for others who do not inhabit a welcoming world.

When it comes to the interpersonal nature of health, we can see that where someone finds themselves in a world matters for the place in which they place health. Gadamer sees health as not fundamentally about how we are engaged with the world: “Health is not a condition that one introspectively feels in oneself. Rather, it is the condition of being involved, of being in the world, of being together with one’s fellow human beings, of active and rewarding engagement in one’s everyday tasks.” [23] (p. 113). That engagement is invited or not also based on one’s environment. In order to imagine myself going forward with my investments, I need to see myself as part of a relatively stable social whole. If health is the possibility of extending into the world where one’s bodily being does not limit this extension but grounds it, the world must be welcoming. Such worlds provide homes from which to extend toward possibilities and homes we can return to when needing rest.

The ability to adapt to changes and be creative in our engagement requires a stable place from which we can ground ourselves. Unstable homes often result in rigid responses in order to establish security, as Laura McMahon writes: “It thus makes sense to call the environments that call forth habits of open-ended plasticity ‘healthy’ and the environments that call forth defensive, rigid responses ‘unhealthy’.” [34] (p. 624). The example of depression above placed stress on the difference between the embodiment of persons with and without depression by highlighting how differences in embodiment shape proclivities toward empathy. A healthy body and stable environment can make empathy challenging for those without either. Since health often operates in the background, it appears just as how things are rather than a matter of bodily constitution and good fortune. The habits that shape our sense of homelikeness develop from a long history of living in environments, spaces, and social worlds where certain norms of behavior are made easy and others are not. I turn next to how these environmental differences shape health.

5. The Social Determinants of Health

A critical phenomenology of health draws attention to aspects of the interpersonal nature of health that are constituted in radically different manners depending not just on one’s embodiment qua bodily state but also one’s situation. Above, I largely focused on descriptions of individual health and phenomenologically inspired possibilities for treatment. However, standard medical care practices or individual adaptivity cannot treat the environment in which one lives. While there may be some individual freedom to creatively adapt to one’s environment, undrinkable water, pollution, lack of access to basic resources, instability, and violence are examples of factors that demand political responses, not individual ones. In distinction from phenomenologies of health outlined above that center the individual, a critical phenomenological view of health can ally with critical public health calls for policy change rather than exclusive attention to individual health.

In this section, I examine the context in which any individual health or illness occurs, the neighborhoods wherein we live and the norms, policies, and histories that determine them. I then discuss how social norms around health are increasingly understood to be an individual responsibility to promote health, instead of previous views of health as something to be attended to by healthcare professionals and individuals only when it is lost. A critical phenomenological approach to health would draw attention to how health promotion deepens social divisions when individual health is addressed without attention to the social determinants of health.

In public health discourse, the social determinants of health are the name given to the ways in which health is affected by aspects of our shared world that do not seem connected to individual bodily health. An environment that welcomes health invites seeing the world as a place for freedom, as a field of possibilities, unless one is ill as a matter of individual constitution. The World Health Organization [35] lists the social determinants of health as “the conditions in which people are born, grow, live, work and age, and people’s access to power, money and resources have a powerful influence on health inequities. These are the unfair and avoidable differences in health status seen within and between countries.” Social and political policies, laws, and histories have created enormous health disparities worldwide; what seems just “normal” for the wealthy is in fact an unimaginable luxury for many. Healthcare resources are distributed unequally globally and within any country or community. In cases of few healthcare resources, illnesses pose a question of survival or not; flourishing or thriving is not a living possibility. Histories of poverty and racism can clearly be tied to poorer health outcomes, demonstrating the long reach of disenfranchisement. The WHO calls upon nations to better recognize these disparities and address them to provide for better health for all.

The primary focus of calls to action from the WHO is to improve the poor health of disenfranchised communities in order to bring those communities closer to the good health enjoyed by the wealthiest and most privileged. If we expand the home metaphor above with Svenaeus, we can notice how any home is situated within a neighborhood. Public health research on neighborhoods and health has increased significantly in the last few decades. It expands upon research with long roots in physical environment and health (such as air quality) to physical aspects of the neighborhood (such as walkability) and to social determinants of health (such as social connectedness or likelihood of violence). One of the most important outcomes of public health research on neighborhoods and health is how it displaces the medicalized view of health as being a matter of individual bodies. Ana V Diez Roux argues that the work in public health research on neighborhoods “has articulated ways in which the environment can affect disease risk factors traditionally believed to be wholly individually determined.” [36] (p. 430). Environmental issues, such as air quality, still can be addressed within a model of individual bodies. But social and political factors like racism and the risk of violence require thinking about embodiment as socially and historically shaped.

A critical phenomenology can help elucidate how to understand how sedimented social norms and political policies affect individual experience. The fact that there are social–political determinants of health confirms a basic phenomenological thesis about our embodiment—that embodiment is not just the skin and what lies underneath—and we are always constituted by the world in which we live.

The challenge is that one’s neighborhood can often appear as what is normal rather than what is contingent, particularly when one enjoys a good one. As with the way in which good health can make empathy for the ill more challenging, an inviting world can make one assume that if people just made a bit more effort, they too could enjoy a healthier life. Different communities in a given society, as well as different communities globally, live in ways that discourage empathetic connections between the wealthy and the poor, given that for the wealthy it is “natural” to see health as the norm, rather than as an exception in disenfranchised communities. The social norm of health varies widely depending upon whether or not one’s environment encourages a creative expression of embodiment. In conclusion, we turn to how contemporary norms of health reinforce the idea of health as a matter of individual opportunity and what that might mean for an outline of a phenomenology of health.

6. Conclusions

Individualized healthcare in nations with advanced technoscientific medical care and for-profit health and wellness industries has radically increased possible ways in which not just illness can be treated but ways in which life can be extended and bettered. This move sharply distinguishes our 21st-century frameworks around health from those of the 20th century, in particular the mid-century work of Gadamer and Merleau-Ponty amongst other phenomenologists, where illness is the center of healthcare rather than health promotion. Medicalization centers illness and difference as problems to be solved. However, increasingly in the 21st century, instead of healthcare as primarily directed toward curing illness, health is increasingly, like wealth, a goal that can never quite be reached. There are always newer and better products and practices to further fine-tune one’s health, not to mention one’s aging body, which brings with it its own host of new challenges. While the medicalized model of treating individual bodies remains, it now is at times uncomfortably inserted alongside a biomedicalized world where health, rather than illness, dominates discourses, public funding, industry investment, and treatment possibilities.

The seeming apolitical nature of the value of health is part of the view of medicalization where moral judgments about individuals are read as “neutral” discussions about medical facts. Health has long been used to advocate for racist and sexist policies and has been used to justify state-sanctioned violence, all under the guise of doing things to better the population. If we are not careful to include the social determinants of health, then all manner of intrusions into individual life can be justified—from the seemingly innocuous bans on certain food or substances, like cigarettes—to larger-scale criminalization of those who violate health norms, as in the war against drug use.

In the first part of the paper, two descriptive themes in phenomenologies of health were presented—one of health as a background state from which illness arises as an issue to be solved. In this model, the goal of the pursuit of health is to ideally find ways to resituate the body’s constitution as tacit so that one can attend to other more meaningful investments. One can easily imagine Gadamer or Merleau-Ponty as examples of this view of health in their prolific philosophical writing and teaching—everyday examples of wanting to get over a passing illness so one can get back to one’s chosen work. The second theme explored how, given the vacillating nature of our bodies and the world, health also requires a normative capacity to respond creatively to change. In some examples, this adaptivity would also be largely tacit—such as the way in which we can easily adjust to changes in the environment like lighting, shifting surfaces, hotter or colder temperatures or various pressures of living with others. Some may require more deliberate consideration, like various kinds of treatment, or deliberate bodily practices to live in a healthier manner. However, even deliberate practices are typically explored as means to permit more free extension in the world, not as closed loops where the only point is to return again to the body.

In a biomedicalized world, health as a matter of personal betterment, the theme of creativity and adaptation to new bodily changes or new environments takes precedence over that first theme of health as being part of a backgrounded state. Instead of seeing the requirement to turn toward the body as a problem, as it is in illness, it would be, in fact, the explicit goal. If one’s primary investment is oneself, then health is about self-improvement, or more cynically, self-exploitation. One would definitively not want to place health into the background but rather keep it front and center as a means by which to be better and fitter and more proactively adapt to challenges one encounters. It is not surprising that current entrepreneurship and influencer gurus are deeply tied to particular deliberate “health” practices as part of their brand, even if the business they sell is itself not necessarily about health. If I can better my health, then so can everyone: a common view of health as personal responsibility or, as I have argued, part of the “good health imperative” [21]. As health pertains to the possible—not just the actual—there is always more to do in service to it. The porous nature of health and how it moves out toward possibilities and between individuals also makes it hard to provide any kind of space in which one can think beyond it. In the larger world of wellness, where all kinds of non-clinical approaches to health management are employed—including those for profit—a similar tendency toward betterment permeates. Any kind of persistent illness is now met not just with what one’s doctor might suggest but with any array of diet and wellness plans with varying degrees of scientific support behind them. Health is now just like wealth, wherein a neoliberal ideology suggests that with a bit more effort, everyone can be wealthy, healthy, and beautiful.

In the previous section, I returned to the theme of social determinants of health. In phenomenological terms, this is the situation in which we live. Any situation, or neighborhood broadly conceived, is a historical and political creation as much as an environmental one. However, many public health calls can be interpreted as just large-scale models of promoting attention to individual bodies and their individual health. For instance, neighborhoods with high rates of violence could be called upon themselves to initiate “community led change” rather than call for policy changes that address the underlying reasons for that violence. While community here might appear to address the social, it does not address the fact that policies, laws, and sedimented social norms fostered the disparate presence of violence. The idea that health is a kind of project that individuals or communities can embark upon with the right attention solidifies the assumption that the cure is intervention into individual bodies.

A critical phenomenological view of health expands upon phenomenologies of illness to explain the ways in which health requires attention to the situation in which one lives—both as a matter of one’s bodily home as well as one’s neighborhood and world. In treatment, the pursuit of health is centrally about the individual’s particular possibilities to work against a standard, reductive medicalized approach. As health requires creative capacity to adapt to change and shape new norms of behavior, health can also reach beyond what is possible in current medical treatments to other kinds of bodily practices that foster freedom. However, behind the background of health there is the constituting nature of the world in which one lives. Many of the features of the world are not open to individual or even community change but require policy changes to shape the world in a manner that permits the kind of creative expression that only those with healthy environments currently enjoy. A further critical phenomenology of health would deepen the connections between phenomenology and public health policy advocacy.