Health and the Life Course
HEALTH AND THE LIFE COURSE
Health and the life course are two broad concepts of interest to sociologists. Each of these concepts must be nominally defined.
CONCEPTIONS OF HEALTH
Health can be conceptualized in three major ways: the medical model (or physical definition); the functional model (or social definition); and the psychological model (or the subjective evaluation of health: Liang 1986). In the medical model, health is defined as the absence of disease. The presence of any disease condition is determined by reports from the patient, observations by health practitioners, or medical tests. The social definition of health is derived from Parsons's (1951) work and refers to an individual's ability to perform roles, that is, to function socially. Illness or impairment is a function of reduced capacity to perform expected roles, commonly measured in terms of activities of daily living (ADLs—eating, dressing, bathing, walking, grooming, etc). The psychological model, or the subjective evaluation of health, is often based on the response to a single question asking one to rate one's health on a scale from poor to excellent. The definition of health used by the World Health Organization since 1946 reflects this multidimensional perspective: "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity."
It has been suggested (e.g., Schroots 1988) that a distinction be made between disease and illness. It is argued that disease refers to an objective diagnosis of a disorder, while illness refers to the presence of a disease plus the individual's perception of and response to the disease. Thus, one may have a disease, but as long as one does not acknowledge it and behave accordingly (e.g., take medicine), one will perceive oneself as healthy (Birren and Zarit 1985).
A distinction should also be made between acute and chronic conditions. These two types of health conditions are differentially related to older and younger age groups (discussed more below). That is, there is a morbidity shift from acute to chronic diseases as an individual ages. In addition, Western societies experienced a dramatic shift from infectious diseases (a form of acute condition) to chronic, degenerative diseases in the late nineteenth century and the first half of the twentieth century.
CONCEPTIONS OF THE LIFE COURSE
The life course is a progression through time (Clausen 1986), in particular, social time. Social time is a set of norms governing life transitions for particular social groups. These transitions may vary from one group to another (e.g., working class versus middle class) and from one historical period to another. The life-course approach focuses on "age related transitions that are socially created, socially recognized, and shared" (Hagestad and Neugarten 1985, p. 35). Historical time plays a key role in life-course analysis because of the emphasis on social time and social transitions (Elder 1977; Hareven 1978). Changes that take place in society lead to a restructuring of individual life courses. Thus, life courses will vary from one cohort (generation) to the next.
The life-course perspective should be differentiated from the life-span perspective or other developmental models of psychology. In these latter approaches the focus is on the individual, especially on personality, cognition, and other intrapsychic phenomena (George 1982). In these developmental approaches, change results from within the individual, and this change is universal—it is a function of human nature. Typically, developmental changes are linked to chronological age, with little or no reference to the social context or the sociohistorical or individual-historical context. The life-course perspective, in contrast, focuses on transitions when the "social persona" (Hagestad and Neugarten 1985, p. 35) undergoes change.
CONCEPTIONS OF AGING
In order to understand health and the life course it is also important to understand the aging process. Aging is best understood in a life-course perspective. Persons do not suddenly become old at age sixty or sixty-five or at retirement. Aging is the result of a lifetime of social, behavioral, and biological processes interacting with one another. While genetics may play a part in predisposing individuals to certain diseases or impairments, length and quality of life have been found to be highly dependent on behaviors, lifestyles, and health-related attitudes (e.g., Haug and Ory 1987).
A distinction is often made between primary and secondary aging (see Schroots 1988). Primary aging, or normal aging, refers to the steady declines in functioning in the absence of disease or despite good health. Secondary aging, or pathological aging, refers to the declines that are due to illnesses associated with age but not to aging itself. This suggests that secondary aging can be reversed, at least in principle (Kohn 1985).
VARIATIONS IN HEALTH AND LIFE EXPECTANCY
The largest cause of death in America for people under age forty-five is accidents and adverse effects (National Center for Health Statistics [NCHS] 1999). For people five to fourteen years of age and twenty-five to forty-four years of age, malignant neoplasms (tumors) rank second as a cause of death. For persons fifteen to twenty-four years of age, homicide, followed closely by suicide, are the next leading causes of death.
For adults ages sixty-five and over the causes of death are quite different. Cardiovascular disease, malignant neoplasms, cerebrovascular disease, and chronic obstructive pulmonary disease are the most common causes of death (NCHS, 1999). Older persons, too, are more likely to suffer from chronic, and often limiting, conditions. Most common among these are arthritis, hypertension, hearing impairments, heart conditions, chronic sinusitis, visual impairments, and orthopedic impairments (e.g., back). Interestingly, these same conditions are among the most commonly mentioned by persons ages forty-five to sixty-four, though their prevalence is generally considerably less than among persons sixty-five and older.
At the turn of the century, life expectancy was about 48 years. By 1950, life expectancy was 68 years (66 years for males and 71 years for females). By 1997, life expectancy had increased to 76.5 years (74 years for males and 79 for females). Many of the improvements in life expectancy came about before large-scale immunization programs. These programs largely affected the health of those born during the 1940s and 1950s. These programs have, however, reduced infant mortality and reduced the likelihood of certain debilitating diseases (e.g., polio).
The chance of surviving to old age with few functional disabilities is strongly related to socioeconomic position, educational level, and race (Berkman 1988). People in lower classes and with less education have higher mortality risk and have higher incidence and prevalence of diseases and injuries. They have more hospitalizations, disability days, and functional limitations.
Life expectancy also varies by social class. At age twenty-five life expectancy, for those with four or fewer years of education, is forty-four years for men and almost forty-seven years for women. For men and women with some college education, life expectancy is forty-seven years and fifty-six years respectively. After age sixty-five, however, this relationship becomes less clear-cut, suggesting that for older cohorts a different set of factors is involved.
Another area where health and the life course intersect is that of health inequalities in the life course. Increasing evidence indicates that many illnesses in middle and later life have their beginnings in childhood or prior to birth (Wadsworth 1997). For example, low birthweight indicates poor prenatal growth, and both are associated with higher risk of respiratory problems in adult life. Further, lower birthweight is associated with poorer health practices of expectant mothers, suggesting that these babies will be born into family/household/social environments that do not facilitate optimal health.
Life course trajectories vary by key social characteristics such as age, gender, race, and socioeconomic status (SES) (Bartley et al. 1997). Further, these life-course trajectories are related to disease risk. For example, an individual born into a poorer or working-class family will have a different trajectory of disease over the life course than an individual born into a family with better financial and social means. The former individual accumulates risks or disadvantages over the life course that begin to show up in adulthood.
ISSUES AND IMPLICATIONS
Differences in health conditions by age raise at least two issues regarding the analysis and understanding of health. First, it has been suggested that in trying to understand the health and health behavior of the elderly, especially as our models become more complex, the individual is the critical unit of analysis (Wolinsky and Arnold 1988). That is, we must focus on individual differentiation over the life course. Aging is a highly individual process, resulting from large inter- and intraindividual differences in health and functioning.
The second issue concerns the extent to which many processes thought to be life-course processes may in fact be cohort differences (see Dannefer 1988). An assumption is often made that the heterogeneity within older cohorts is an intracohort, life-course process: Age peers become increasingly dissimilar as they grow older. This conclusion is, however, often based on cross-sectional data and may lead to a life-course fallacy. Age differences may reduce to cohort differences. If each succeeding cohort becomes more homogeneous, older cohorts will display greater heterogeneity compared to younger cohorts. Evidence suggests that for several cohort characteristics this may be the case. For example, there has been increasing standardization of years of education, age of labor-force entry and exit, age at first marriage, number of children, and so on. Thus, younger age groups would exhibit less diversity than older cohorts.
Not all health deterioration is a normal process of aging. Some of it appears to be the result of an accumulation of life experiences and behaviors. Many of the experiences and behaviors are different for older and younger cohorts, suggesting that an understanding of factors affecting health for older cohorts may not hold for younger cohorts as they age.
Two possible scenarios exist. One is that older people in the future will experience less morbidity than today's elderly, even though later life will be longer. That is, they will be older longer, sick for a very short period of time, and then die. An alternative situation is one in which elderly live longer and are sick or impaired for many of those years. That is, they will be sick for an extensive period of their later life. Given the fact that more people are living longer, the general expectation is that the demand for health care by the elderly will be greater in the future. The extent of the demand will depend, in part, on which of these two scenarios is closer to the truth. The conservative approach, and the one generally adopted, is that estimates of tomorrow's needs for care are based on data from today's elderly. However, a life-course perspective might yield quite a different picture because the life experiences, behaviors, and health attitudes of today's elderly may be quite different from those of younger cohorts, tomorrow's elderly.
Health is a lifelong experience of an individual, composed of accumulations of risk. Logically, reducing health problems in middle and later years will be more successful the earlier attempts are made to reduce these risks (Wadsworth 1997). Similarly, health inequalities exist, and these are associated with social and biological characteristics of individuals (e.g., gender, race, SES). Reducing health inequalities will require reducing risk factors for these different groups of individuals and doing so early in life.
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Donald E. Stull