10Health as a Family Matter
LINDA C. GARRO
What is involved in considering health as a family matter? To start, it bears noting that a different orientation to health is far more pervasive in research and everyday life contexts. In both, health is typically construed as a largely individual-level concern—a framing of health as “personal well-being.”1 In the United States, for example, the commonplace greeting in daily life, “How are you?,” provides an opening for individuals to reflect upon their personal state of health (or well-being). There are manifold sources offering guidelines concerning actions individuals can take to improve their health and well-being and/or to minimize risks to health and well-being. In research settings, individuals may be asked to rate their overall health or asked other questions designed to measure an individual's health status and/or to learn about aspects of an individual's life with the potential to have an impact on present or future health. Further, even when aspects of the social environment, including family relationships, enter into the research design, the focus typically remains at the individual level. Such would be the case, for example, when a research project explores whether variations in the health status of individuals is associated with variations in the quantity or perceived quality of relationships and/or responsibilities. Rarely does the attention shift from assessing impacts on individual health to the consideration of matters of health as lived in concert with others in quotidian social settings, such as family life contexts.
The existing research emphasis on individual-level health in medical and psychological anthropology (my own fields of academic specialization) as well as in medical sociology in North America and Europe may, at least in part, be linked to the reliance on interviews with individuals as a primary research method for both eliciting conceptual understandings about health and learning about the experiential dimensions of health. Nonetheless, methodological considerations alone are insufficient as a full explanation for the emphasis on individual-level health. Some researchers have expanded the interview's typical horizon to ask about health-relevant activities as embedded in everyday family life,2 or relied on interviews as one tool for assessing well-being, such as in the work of Thomas Weisner, who defined well-being in relation to the sustainability of a family's meaningful daily routine and the positive “states of mind and feeling produced by participation in routines and activities.”3 Interviews, by themselves, do not preclude studying health as a family matter.
Buttressed, perhaps, by the way “objective” measures of health and well-being are geared to assessing individuals, the emphasis on individual-level health may also be linked with the proclivity to privilege subjective experience as the primary locus of health and well-being.4 In this light, a key factor for personal well-being “is not how healthy you are, objectively, but rather how you feel about your health.”5 An illustrative ethnographic example drawing on field research in Toraja, Indonesia, is provided by Douglas Hollan. Hollan characterizes “being well” as “inherently a contingent, subjective state,” a “dynamic state of being that is related to fluctuating states of body and world and the interaction between the two.”6 Still, even in this depiction of well-being as self-related experience, Hollan's rendering of the ebb and flow of a sense of well-being for one Indonesian villager across the course of a day unfolds in the context of a particular sociocultural environment, in specific sites (including the home), and in relationships with specific others (including family members). While the theoretical argument in Hollan's article centers on variation in subjective experience at the individual level, the ethnographic portrayal establishes the need for attention to the broader social surround and the intersubjective ground of health and well-being.
In this chapter, without dismissing the import of health and well-being as self-related experience or as individual-level concern, I broaden the analytic lens to explore health and well-being as ensconced in everyday family life and as bound up in relational connections with other family members. I start from the position that if the goal is to understand how matters of health, well-being, and illness enter into the microcultural context of family life, we must attend to what matters to family members in their daily lives.7 With regard to the CELF project, an appreciation of what matters to family members is garnered through conjoint analyses of the ways family members talk about health and health-relevant matters with researchers, especially in the parental interview on health and well-being and the video recordings of family life. As each family is unique, analysis has centered on developing what I refer to as an individual “family health portrait.”8
In comparison with research where individual-level health serves as the primary orienting framework, a family-level approach that revolves around what matters to family members situates health and well-being in a larger social arena and thus expands potential avenues of research inquiry. For instance, what do we learn about family life and raising a family when examined through the lens of health? In what ways are health and well-being matters of concern in the often hectic lives of working families? To what extent are the video-recorded observations of everyday family life illumined by health-relevant parental commentary elicited through our research—such as interview statements and comments directed at researchers during the video recordings? Do matters of individual health and well-being take on a different cast when the family sphere is considered? Does health as a family matter refer to something more than the sum of the personal health of the individuals who make up a family? Do parents perceive economic, material, or other factors as connected, positively or negatively, with family health and well-being? How do matters of health and well-being relate to other priorities, obligations, compelling concerns, and expectations, including hopes and fears, for the present and future?
These are, to be sure, broad and complex questions that cannot be fully addressed in a single chapter. Still, they encapsulate some of the issues regarding health and well-being that arise when the research gaze expands to consider health as a family matter.
This chapter draws on the family health portraits of two families in which the father smokes cigarettes and drinks alcohol (beer) on a regular basis, to explore the relationship between family well-being and these habits, especially smoking. These two families were not selected because smoking is common among the CELF families. It is not. And while there are other families in which one (or both) of the parents smokes cigarettes, a similar heightened concern about this habit was not present in these other families as it was in the two families showcased here. Rather, attention to the issue of smoking within these two families serves to illuminate the recurring “tug of the individual and the communal within the family"9 with regard to matters of health and well-being. In different families, the contours of a socially embedded and relational view of health take different shapes and intertwine with health as an individual concern in divergent ways. The different ways in which fathers’ smoking becomes a matter of moral reflection and contention in the two families offers an entrée for exploring the complex interrelationships between health as a matter of “personal well-being” and health as a matter of “family well-being.”
Before turning to these two families, some additional introductory comments concerning the cultural landscape of health and well-being help to set the stage. As noted above, much of the existing research relies on interviews to explore how individuals think about health. Although not fully explored here, there are numerous points of correspondence between what CELF parents had to say and the literature reviewed in the following section.
THE CULTURAL REALM OF INDIVIDUAL HEALTH AND WELL-BEING
With health conceptualized as a notion bounded by individual bodies and minds, one claim is that the cultural ideal of a “disease-free, fit, and youthful body” serves as a desideratum and comparative benchmark in “an individualistic, industrialized, modern world.”10 Moreover, studies carried out in the United States and the United Kingdom attest to the widespread acceptance of the view that “the responsibility for health and illness is in one's own hands,"11 a stance that situates “problems of health and their solutions principally, although not exclusively, as matters within the boundaries of personal control.”12
Overall, and as also observed in the CELF interviews, framing health and well-being as ends that in important ways require “choice and active commitment"13 imbues much talk about health and well-being in the United States and the United Kingdom with a characteristically moral quality.14 Idealized cultural expectations about what one should do with regard to health take form through what will be referred to here as the model of “individual health promotion.” This model brings together the positive valuation of behaviors deemed to enhance health with the moral standard that individuals should actively strive to adopt “healthy” behaviors and refrain from those considered injurious to health. The culturally grounded pursuit of health is underpinned by a “morality of the body in terms of what is good and bad. Actions regarded as good for the body are lauded while actions deemed bad for the body are to be avoided. In this moral world, for example, exercise is deemed ‘good’ while junk foods are ‘bad.’’’15 Prototypically, the “individually-based oughts of so-called healthy behaviours"16 are rather “conventionally defined primarily in terms of smoking, diet, exercise, and alcohol or other drug consumption.”17
Drawing on interviews carried out in Chicago during the 1980s, Crawford asserted that “the quest for health” is “a distinctive feature of middle-class identity and belonging.”18 Thus, to “the question, ‘How should I live?’, the denizen of medical culture answers, ‘Healthfully’. Behaviors are modified and lifestyles constructed in response to information about dangers to health.”19 Whether or not the individual health promotion model, and its associated optimal behaviors, carries as much directive force as Crawford suggested, the apparent widespread consensus among the middle class in North America and the United Kingdom that one “should” live in relatively close accord with the behavioral mandates of the individual health promotion model increases the vulnerability of individuals to moral critique, censure, and self-blame for the observed or presumed failure to live as one “should.” The “morality of the body” demands an accounting if blame is not to be assigned to the individual. Conversely, the achievement of health and efforts to comply with the directives of individual health promotion are marks of moral virtue.
From the perspective of individual health promotion, parents are charged not only with optimizing their own health but also with optimizing the health of their children and, beyond that, for socializing children to appreciate their own independent responsibility with regard to health and well-being. A family in which individual health is accorded its moral due is a family in which the parents demonstrate an appropriate level of adherence to the mandates of individual health promotion through talk and other action. A failure to do so, or being assessed as failing to do so, places parents at risk of being seen in an unfavorable moral light by others. They may also come to judge themselves as being at fault. Interestingly, an analysis of video recordings of family mealtime interactions found that “American families devoted most of the dinner discourse to what children must eat for physiological and moral reasons.”20
Still, not all influences on individual health are seen to lie within the purview of individual responsibility. For example, in the CELF interviews, “stress” as part of everyday work and home life as a potential source of ill health and diminished well-being was at times conceptualized in ways analogous to air pollution—a feature of one's general environment, but largely outside one's personal control, that has deleterious impacts on health and well-being. Such an explanatory framework establishes connections between lived experience and states of health and well-being in ways that offer possibilities for eliding the discourse of personal control. While steps may be taken by an individual to minimize or avoid exposure to such sources of ill, notions of personal blame or responsibility may not inform whatever deliberations lie behind such actions.
So far, the discussion has centered on what leads someone to be healthy or not, on the causes of good or ill health, without setting bounds around the concepts of health and well-being. At a definitional level, while some scholars do not explicitly distinguish health from well-being, others find it useful to characterize health as a component of well-being that signals attention to physical well-being. For example, as part of their efforts to develop “a cross-cultural comparative schema” for research purposes, Mathews and Izquierdo posit several “experiential dimensions” of well-being.21 One is characterized as “a physical dimension of well-being, involving how individuals conceive, perceive, and experience their bodies in the world.”22 A further subdivision of this physical dimension differentiates between “conceptions of and experience of pleasure (short-term physical well-being) and health (long-term physical well-being).”23 While other scholars do not necessarily define the realm of health exclusively in relation to the physical (or the long-term), neither is it the case that the discussion of the physical is absent from studies of health. In much scholarly work, to speak of health is to implicitly include physical wellness.
On the other hand, the notion of well-being may be preferred by scholars when the emphasis is on subjective states, for example, when privileging “happiness” as “the most essential part” of well-being.24 In anthropological writings, the use of “well-being” may also gesture toward a “broadening of the concept of health” to include “people's views and rationales concerning good feelings and good lives.”25 Mathews maintains, “Well-being is not only a matter of physical health; it has an existential component as well. In order to fully experience well-being, people everywhere need to feel that their lives are worth living.”26
Despite such efforts, it remains inherently problematic to set definitive boundaries around the conceptualization of health or to clearly delineate what is further entailed by the notion of well-being. Instructive in this regard is Blaxter's book, Health.27 At the end of an extensive review of primarily European and North American research, in addition to a consideration of health through a historical lens, Blaxter concludes that “health” is and “has always been a slightly slippery concept.” Moreover, “the theme” of her book is “not only that a single all-purpose definition of health is impossible, but that attempts to impose one have never been very functional.”28
Certainly, judging by the range of answers given by interviewees across studies in North America and the United Kingdom, there exist quite diverse ways in which the rather abstract notion of health can be defined and otherwise endowed with meaning. In a recent study carried out with an ethnically diverse sample in Chicago, after individuals provided a rating of their own health, researchers followed up and asked what the word health meant vis-à-vis the rating task. The responses revealed at least nine “different ways in which the idea of health can be defined and given character,” illustrative of the way that “the English word health . . . is not unitary in meaning and indexes a wide variety of intuitions, images, and implications about personal well-being.”29 Blaxter's analysis of a nationwide U.K. survey discerned five main categories for how people defined health, namely: health as not ill; health as physical fitness; health as the quality of social relationships; health as function; health as psychosocial well-being.30
Perhaps unsurprisingly, interview-based health-oriented studies align with a view that there is no tidy differentiation between health and well-being. The formulation of health as “psychosocial well-being” advanced in the U.K. study, for example, comprises “expressions of health as a purely mental state, instead of, or as well as, a physical condition.”31 And somewhat comparable to the conceptualization of health as the quality of social relationships32 is Mathews and Izquierdo's “interpersonal dimension of well-being,” which pertains to “how individuals conceive, perceive, and experience their relations with others.”33 More generally, a Chicago-based study involving primarily middle-class persons asserted, “Talking about health is a way people give expression to our culture's notions of well-being or quality of life.”34 Prominent intersections for constructs of health and well-being include the importance of “feeling good” and experiencing “pleasure.”35 Along similar lines, another U.S. study of “white, middle-class men and women” concluded that the “idea of health was closely associated with the idea of ‘well being'; that is, abstract notions of health and healthiness were identified with positive aspects of ‘being’ in the world and were grounded in lived experience.”36
Clearly, even when the focus is on health and well-being at the level of the individual, the terrain is complex. In addition to the importance of “individual health promotion” as evidenced in the cultural stress placed on individual responsibility and personal control, this brief review gives some sense of the wide range of definitions, concerns, and issues that have emerged in previous research. As we have seen, although there is a tendency for health to be associated with the physical body and for well-being to align with subjective assessment, the terms defy straight-forward definition. Rather, health and well-being are flexible, broad, and somewhat nebulous constructs, complicating any effort to demarcate the arena of health and/or well-being or to clearly differentiate between the two notions. The situation becomes only more complex when studying health and well-being as embedded in everyday life.
With this definitional discussion as a backdrop, the next sections offer minihealth portraits of two families, with particular attention to the connection between the father's smoking and familial relations of care. Going beyond the view that smoking is “bad” for the smoker's physical health and for those exposed to secondhand smoke (neither of these issues were matters of controversy in the two families), the discussion reveals how smoking, when framed as a family matter, can assume a moral cast different from when health is construed solely as a matter of personal concern. For the first family, the Morris family, this “morality of care for family” corresponds with and adds weight to the “morality of the body” at an individual level, leaving the smoker asserting his personal right to make the choice to smoke. In the second family, the Casey family, the dilemma is that these two moral demands are in direct conflict.
SMOKING AND RELATIONS OF CARE
The Morris Family
On the last day of filming, a Sunday, Dale Morris was observed smoking (for the second of three times during the video recording) outside the family home. Dale spends a lot of time outside the home, often in the garage. Furnished with a reclining chair, a refrigerator stocked with beer, and a television set, the garage was the space where Dale had been recorded drinking beer on several occasions. On this Sunday, Dale's wife, Kelly, was away on an errand and Dale was keeping an eye on the family's two adopted children, nine-year-old Mark and two-year-old Tessa. Dale and Kelly's seventeen-year-old daughter, Celia, an attentive, reliable, and frequent caretaker for her younger siblings, was also at home. With Tessa taking a nap and Celia within call, Dale supervised Mark's preparations for skateboarding and watched him take off down the sidewalk. Noticing Dale's concerted efforts to keep the lit cigarette out of view, the videographer asked Dale whether he would prefer that his smoking not be captured on film. Dale replied that he didn't care about the video recording but that “this will probably be the only time on tape that you got it.” With apparent concern that Dale was not at ease smoking in the presence of the camera, the videographer told him, “I smoke” and “It's okay, it's okay.” Dale repeated that it didn't matter and explained: “I just mainly don't let the kids see me.” After the videographer pointed out that she had never seen him drink beer inside the house either, Dale said, “I try not to let them see any of that.” He then said that it wasn't so much the drinking that was an issue as “we have barbecues and stuff like that.” Smoking, in contrast, “I hide.” Dale went on to acknowledge that Mark has seen him smoke but then minimized these instances by claiming, “He doesn't see me [smoking] enough to really remember type thing, and the baby I don't let see me at all.” Describing a couple of strategies he used to keep his smoking out of sight, Dale asserted that most of his smoking was at work, and, he explained, “I don't really smoke that much unless—I'm about a pack a day.” Overall, “I really don't smoke too much at home anyways.”
Dale claimed to “love being outside,” and he was indeed observed spending the majority of time outside doing chores in the yard or garage or watching sports or the evening news on the television he has installed in the garage while sipping a can of beer. Kelly's domain is inside the home, and she took on a greater share of household responsibilities and had greater involvement in childcare. Compared to other CELF families, this gendered spatial division of labor was somewhat more pronounced, as was the fact that Kelly was largely responsible for making financial decisions, even quite significant ones such as purchasing a combination rental/vacation home on Catalina Island. That the family enjoys a relatively comfortable economic position was credited, by both parents, as being largely due to Kelly's efforts.
Portraying themselves as “older” parents, Kelly and Dale were in their early forties at the time of the study. In the health interview, the children take center stage as what makes life “worth living"37 for the Morris parents. Kelly talked about having the children as a key goal that “I wanted and we've achieved.” Being an “older parent” gave Kelly an “incentive to be healthy” and “be as active as I can and keep young” in order to fulfill her plan of “being here for a while” for them. Dale followed up, saying, “That's my thing too, that's what really drives me to get up and go to work cause we're doing it for the kids.” As a couple who “have always enjoyed kids,” both aver that the addition of the two younger children to their family has, in Dale's words, “made us healthier people.”
These parental reflections seem striking given the challenges they have faced in dealing with the health problems of their two youngest children. Both were born with substance addictions and had troubled medical histories prior to being adopted by Kelly and Dale. Kelly described the children as “drug babies” and attributed Mark's diagnosis of attention-deficit/hyperactivity disorder (ADHD) to the alcohol and several illicit drugs that his biological mother ingested while pregnant. Tessa, whose biological mother was addicted to heroin, was considered essentially recovered from the trauma of her birth circumstances.
Dale and Kelly reported that they had always hoped to have more than one child and when, after Celia, they found themselves unable to have additional children of their own, they decided to work toward adopting a child who needed a family but who was otherwise unlikely to be adopted. Both parents were committed to the view that parental dedication and providing a stable home environment were necessary in order for children to flourish in the present and succeed in the future. With regard to their children, Kelly, in particular, conveyed how she was steadfast in her efforts to “bring out the best in them” and help them find their “niche.” She was confident that despite the birth circumstances of her two adopted children, she could enable their future success by creating quality environments for them (this seemed to be a challenge that gave Kelly a particular sense of purpose). Her efforts were not just confined to the family home, but extended into other environments, such as school.38 Interestingly, Kelly also linked the decision to adopt with concern about Celia not having siblings and the implications this might have for her future: “The reason I would never ever ever have only one child is because when your parents get up in life or whatever, the burden of your parents and the burden of doing things falls on your children.” Outlining the expected course of events as one where parents need the help of their children, Kelly stated, “It's nice to have that brother or sister to call and say, ‘I need you, I need you now'” “I never wanted Celia to ever have to go through any of that by herself.”
At an early point in the health interview, after addressing the question “What is it like when you are healthy?,” Kelly added, “I have no tolerance for sick people.” She explained, “I hate dealing with sick people. I hate dealing with illnesses. I hate—,” followed by Dale's interjection, “We've dealt with a lot of death.” As the conversation continued, and throughout the interview, details about the heavy burden of illness and loss among extended family and others close to them bore out Kelly's laments, “I've dealt with sick people all my life” and “We've had more than our share [of sickness and loss].” At the family level, when “someone is struck with an illness it puts a lot of stress and a lot of fear into a family.”
Despite Kelly's affirmation “I hate having to always be the responsible party in the family,” her view of herself as a moral person includes “being there for” others. While Dale strongly feels the commitment to “be there” for others as well, he affirmed that Kelly has assumed much of the burden by repeatedly taking on the role of caregiver and by providing emotional and material support when intimates are in need. Among the challenges faced by the family are the deaths of the children's grandfathers. Dale's father, a coal miner who is described as having smoked and drunk heavily, succumbed to lung cancer. Kelly's father, who had been “sick” for Kelly's “whole life,” was described as a chain smoker who consumed four to five packs a day and “died from smoking.” A relatively recent loss was Kelly's oldest brother, a troubled Vietnam War veteran with a “really bad circulatory problem,” who became “addicted to prescription drugs.” Even though Kelly saw her brother as lacking a source of motivation and satisfaction until close to the end of his life, she concluded that he “caused his own problems” because he “abused his body way too much,” eventually leading to his death. Kelly's response to the health interview question of what keeps people healthy combines “a good outlook on life” and “taking care of themselves, not abusing their bodies” by drinking, smoking, and taking drugs. More generally, both Dale and Kelly perceive the world around them as full of hazard and the future as uncertain.
Even though “being there” for others during times of disappointment, grief, and hardship can take a “huge toll on you,” it is a responsibility that one owes to family. Yet the imprint of this value orientation is not just restricted to times of trouble; it is found in routine everyday life contexts as well. In a previous article concerning this family, Garro and Yarris detailed how familial interactions evidencing a sensibility of mutual care and concern, along with parental efforts to motivate younger children to act in ways that “help” others, are consistent with an implicit moral stance that a responsible person is one who helps others and responds to the valid needs of others by placing these needs ahead of one's own convenience, pleasure, or comfort.39 In addition, sacrifice may be rewarded—a person's willing acts to help another potentially benefits the helper as well; it is more likely that others will be willing to be there and help you if you take the initiative to contribute to what others seek to achieve and be there for them across good times and bad. Given Dale's and Kelly's efforts to raise their family in a manner consistent with these values, Kelly projects a future in which her grown children willingly accept the “burden” of helping aging parents. Through everyday interactional work fostering “moral responsibility in the form of generative cross-situational awareness to others’ needs and desires” and supporting the development of “social awareness, social responsiveness, and self-reliance,"40 Kelly and Dale strove to shape what sort of persons their children would become.
Along these lines, their teenage daughter Celia's interview is illuminating. Asked about the meaning of family, she replied, “Family to me, it's just a—I don't even think of the bloodline thing, you know, being related to your family. I think it is just a group of people who truly care about each other more than anything in the world and would do anything for each other . . . So it's just people who care about you so unconditionally and take the good with the bad with the ugly.” Affective relationships and acts of care, rather than biological ties, are the constituents of family. Celia, who was observed to take an active role in caring for her younger siblings and to willingly pitch in to help address small unanticipated problems, minimized her own contributions: “It's not like—it's not a big deal really for me to help out my family because they do, I think, ten million more things for me than I do for them.” After listing a number of concrete acts as instances of caring for which Celia was recipient, she summarized the situation by avowing: “My family is very willing to sacrifice to help.”
Because parental interactions within the Morris household were typically pleasant and not confrontational, the section of the health interview during which Dale's smoking and drinking was discussed stands out as rather tense. Kelly's grievances arise in the discussion about things that have an impact on the health of the family. At first environmental concerns—"toxins” and “pollution"—were raised, largely unavoidable especially as the family home was located close to a major international airport; and then the deleterious effects of “quick fast foods” and “preservatives” were mentioned. After Dale indicated that he had nothing further to contribute on this topic, Kelly raised the issue of “when me and Dale fight.” Pointing out that “everybody” fights, Dale disclosed that “money” was “pretty much the bottom line” for their arguments. Kelly concurred but expanded the list to “money, drinking, and smoking.” Kelly presented herself as a careful manager of the family's resources and complained that Dale, in contrast, “doesn't realize how much money he spends every month,” particularly on cigarettes and beer. Kelly views these purchases as siphoning off fiscal resources that should be used to support the well-being of the family rather than to contribute to its vulnerability. Still, the threat to family financial stability, while important, was just the tip of the iceberg, as seen in the following excerpt:
| KELLY: | I just have a real problem with him drinking beer everyday and him smoking everyday and that it takes a toll on his health, he's starting to look very old, and um– his children are seeing it, and when we've got two babies that are drug addict—one's an alcho– a fetal—had fetal alcohol um it's not fair to them to see that every day. | |
| DALE: | They don't see that every day. I don't smoke in front of the kids. | |
| KELLY: | But they know that you're doing it. | |
| DALE: | NO they don't. Celia does. Mark doesn't. Mark really—I don't think has a clue. | |
| KELLY: | Oh he has a clue— | |
| DALE: | mm okay and Tessa I don't— | |
| KELLY: | SO he gets very upset when I bring it up he gets very pissed at me, but, you know what? I'm not going to sit there in the hospital with him every day, you know. And that's a huge thing, it's a very huge thing to me. And he doesn't think about it, but I do. | |
| DALE: | Yeah, the reason I don't is because I can go tomorrow. I, you know, I don't—I don't know I just take it a day at a time, and ((pause)) if tomorrow never come it never comes at least I've done what I wanted to do up until that point in my life. |
Kelly's critique of Dale's smoking and drinking gains depth in relation to the familial history of loss, the adopted children's past as “drug babies,” and the familial orientation to valuing acts of mutual care and concern. For Kelly, that Dale is apparently unable to contemplate the present and future toll of his smoking and drinking on both self and family is a “very huge thing.” In her view, his daily indulgences are making him “look very old,” thus negating other efforts to counter the effects of age and extend health as long as possible in the future to “be there” for their children. For the two children born drug addicted, having a parental role model who smokes and drinks is not “fair to them.” In addition to denying the “morality of the body,” Dale is denying his moral responsibility to his family by choosing to smoke and drink without taking heed of the way that threats to his own well-being are also threats to the well-being of his children and wife. Predicting a future time when Dale will be seriously ill as a consequence of his own choices, and reverberating with painful experiences of past losses associated with drug use, Kelly's scenario is one in which she refuses to take on an additional burden by being physically present at his hospital bedside as she has been for other family members in the past. By alluding to a future in which she abandons a central tenet of her moral persona, namely, to “be there” for family, the gravity of Dale's past and present actions and their future consequences are underscored. Through his own actions, Dale's entitlement to Kelly's caring presence in the hospital is forfeit. In response, Dale offers an alternative scenario in which the cause of his eventual demise is not so easily foretold given the omnipresence of other sources of danger. He highlights the fact that this is something he does for himself. His avowal that if tomorrow “never comes at least I've done what I wanted to do until that point” is an explicit refusal to accept Kelly's framing of his smoking and drinking as a family matter.
Following the interaction quoted above, Kelly expressed her strong conviction that Dale should “respect what I'm asking.” She reported, “There's times when I've just pretty much told him, ‘I don't want to deal with this anymore. Let's get a divorce.’ Because it's just, you know, but he has made the conscientious choice not to cut back.” Dale, firmly sticking to his position of personal autonomy, bluntly retorted, “I will be my own man.” Although he recognized the “downside” of the effect of his smoking and drinking on his personal health, it was “part of my living” and a stance that Kelly should respect and tolerate, as these habits did not negate his ability to be a good father and husband.
In the health interview, as additional support for her construal of Dale's failure to consider others, Kelly turned next to Celia. Establishing a connection between the “toll” on Celia and Kelly's experiences with her own father, she related: “Celia hates it. She has come to me crying over it, and she hates it, and she has asked him ever since she was a baby for him to quit smoking. She has told him point blank, ‘All I want for my birthday is for you to quit smoking.’ So, you know, if that doesn't make him quit, when your own baby daughter doesn't make you quit, then you know it's pretty hard. And my dad died from smoking so see it's a very a double edge sword for me.” Kelly's moral high ground gained further elevation as she recounted how she gave up drinking alcohol, essentially for good, when she first became pregnant, because responsibilities to other family members come first (along with childcare, she included being the designated driver for Dale). In line with the way relations of caring infuse family life, the safeguarding of family health and well-being takes precedence over personal desires. The morality of care for the family is, in part, enabled by the morality of the body.
Shying away from talk of addiction or habit, and framing smoking as a want rather than a need, Dale seeks a place to hold his ground by asserting the moral right to decide for himself, including his ability to devote part of his income to alcohol and cigarettes. Yet despite the defense Dale mounted in the health interview, his continuing efforts to “hide” his smoking while at home and to minimize his drinking in the children's presence reveal that there are limits to what it means to be his own man in the familial context. Dale's own actions confirm that not smoking inside the family home is part of the optimal home environment that both parents voice commitment to in the health interview. Yet by smoking on the home's perimeters, as well as coming home from work with clothes reeking of smoke, as one interaction tellingly revealed, Dale does not measure up to Kelly's standards of responsible parenting. And while Kelly's multifaceted critique ostensibly targets what both portray as Dale's refusal to give up smoking and drinking, it is also a statement of the ways in which family health and well-being are made vulnerable through this refusal. Kelly's placing of limits on her moral obligation to “be there” for others, to the “bad and the ugly” that she will accept from a family member, stands as a warning to Dale that his inconsistency in recognizing the moral interdependence of the family with regard to matters of health and well-being may cost him not only his personal health but also exclusion from the benefits of familial interdependence at a time when he needs that support.
The Casey Family
In the Casey family, the father's smoking and drinking is neither hidden nor censured. Both are part and parcel of family life in a way that would be unimaginable in the Morris family, and these habits are not singled out as significant threats to family well-being. But then, in contrast to the Morris family and many other families in the CELF study, the Casey family's economic situation at the time of the CELF study was far more precarious. Just a year earlier, the Casey family—consisting of Ronald, or Ronnie, the father, Melissa, the mother, Amanda, their eight-year old daughter, and Michael, their four-year old son—would not have been eligible to participate in the CELF study because they did not own a home. Although both parents were clearly pleased to be home owners, Ronnie explained that purchasing their unpretentious home was “a miracle, a blessing in itself,” given that they were “barely getting by at the time” and had “very little savings.”
Financial concerns have troubled Ronnie and Melissa throughout the fifteen years they have been together. Both Ronnie and Melissa have worked hard and made sacrifices in order to improve their family's financial situation and overall security, and both were optimistic that better times lay ahead. Melissa, who worked as a school counselor, had recently completed an advanced degree. Still, at the time of the research, the degree had not yet led to a markedly better job and higher salary. Ronnie worked in construction and was in the penultimate year of a five-year apprenticeship as an electrician. Ronnie's income fluctuated depending on the availability of work, and he did not accrue any “sick time.”
Although the recent house purchase represented the fulfillment of a family “dream,” it was also the source of financial strain, especially given the renovations that were needed to make the dwelling habitable. Ronnie maintained that “financial stability is really our main concern. It's, it's a constant juggling of bills, uh. Puttin’ this off, puttin’ that off.” Financial worries and the constant press of everyday obligations at times led to “moments of explosion and hair pulling.” Ronnie explained: “You know, we as a family have learned that there's so many things that can stress us out on a daily basis.” Near the end of the video recording, Ronnie stated he was “sorry” that we hadn't caught any of these moments on film as it would help us to better understand “stressed-out families” like his.
In conversation with CELF researchers, Ronnie characterized his cigarette smoking as both a “horrible, disgusting habit” that he intended to quit and a “medical need,” legitimated by his diagnoses of ADHD and bipolar disorder—a way to avert eruptions of anger when he is “stressed out.” Without entering into a discussion of the validity of these diagnoses, here the focus is how Ronnie's smoking and drinking enter into everyday family life. While Ronnie's voice predominates, for he had much to say in conversations with the videographer while he smoked a cigarette outside the family home, it is Melissa, in particular, who viewed Ronnie's smoking as bound up with family well-being in ways that foreshadow potential dangers should his expressed intention to quit smoking become realized. By supporting Ronnie's emotional stability his smoking and drinking are credited with maintaining both the daily emotional well-being of the family and the family's financial well-being, the latter by enabling Ronnie to hold down a job.
It was not until the second day of filming that Ronnie made his first appearance on video. The previous evening Ronnie had been at school, arriving home after the CELF researchers had left. On days when he is not taking courses for his certification as a professional electrician, Ronnie is often the first family member to arrive home. Meeting the research team as he arrives back from the corner grocery store, Ronnie explained that he typically uses the interim between his arrival and that of the remaining family members to prepare the evening meal. On this day, between leaving work and going to the grocery store, Ronnie purchased some “emergency food” from an Asian market as he was worried that what he had planned for that evening might not be enough. As he chopped vegetables, Ronnie explained that the store-bought food was “home cooked” and not “junk food.” He continued:
‘Cause believe it or not I'm the one that tries to keep everyone away from the cheeseburgers and the french fries. ‘Cause if it was up to my wife, three times a day, she could probably. But I—It's become a personal mission here. I have to get some kind of nutrition into this family otherwise it would be chaos. She was raised on taquito night, you know.
A bit later, Ronnie pointed out that it is difficult to come up with nutritious food that his family, particularly his children, will eat. Nonetheless, he stated that he enjoys cooking because “it's the one time out of the day where it's my time . . . I like it. You get to be creative and know you're doing something good for the family.”
Included among the items purchased at the grocery store was some bottled beer. Prior to beginning the meal preparation, Ronnie pulled a beer out of one of the grocery bags.
| RONNIE: | If you don't mind if I have a beer. I'm a little nervous with eyes on me. ((Ronnie opens the bottle and takes a drink)) I have a beer every one or two every couple of days out of the week maybe. | |
| VIDEOGRAPHER: | Uh huh. | |
| RONNIE: | Generally it gets the edge off of me so I don't unleash it on the wife and kids you know. I go through quite a bit at work. |
Note that Ronnie's beer consumption, initially attributed to nervousness, is put forward as a general strategy for protecting family members from his work-related strain and the effect it has on him. On another occasion, Ronnie referred to being “hepped up” by caffeine and needing to drink beer to calm down.
During her video-recorded home tour, Melissa included the outdoor picnic table where “Ronnie does his little smoking.” And indeed, near the end of the family dinner, Ronnie announced he would be “back in a minute” and sat down at the table for a smoke. These departures are a recurring activity that punctuates the rhythm of everyday life and may be accompanied by a comment that he needs to smoke or take a “nicotine break.” On this occasion, Ronnie and the videographer chatted about the upcoming Christmas holidays, and then Ronnie brought up his smoking. In the transcript below, note the parallels to how Ronnie talked about his beer consumption as protective of others.
| RONNIE: | I plan on quitting ((pause)) smoking after the holidays. | |
| VIDEOGRAPHER: | Yeah? | |
| RONNIE: | I quit for eight months last year, then I bought the home. It was either start up smoking again or people were going to get hurt. ((pause)) I was really: stressed out. It was very stress—stressful moment in my life, I'm ((pause)) I didn't know stress until we bought this house. It was just uhh—I was in shock for months after the fact. ((long pause)) Doesn't look like much to some, but ((pause)) there's still a lot of work. I (only) have so many more plans for this house. |
The health interview provided another platform for Ronnie to introduce the topic of smoking. Near the start, in response to a general question about the meaning of health, Ronnie reported: “Hasn't meant much, I guess, until the past couple of years. I never took care of myself.” Then, defining health as being “able to function well every day,” he stated, “I abuse myself but, yeah, that's basically it. Just to be able to function well everyday mentally, physically.” He raised the plan to stop smoking after the holidays again and retold the story of quitting and relapsing with the stress of the house purchase. Then Ronnie disclosed a relatively recent change in his eating habits, revealing his avowed “mission” to feed his family nutritious foods as also relatively recent. Ronnie recounted that he had been quite overweight ("pushing 300 pounds") and that there is a “definite difference” in the way he eats now. He said of the past: “I didn't care. I felt, you know, it's my life. We're here for a blank of time anyways, you know. I'm going to live happy.” Characterizing himself as “not much of a down-the-road type of guy” and more of a “now” person, he nonetheless realized, “I want to be able to have the time and health to spend not only with my kids growing up but possibly their kids.” On another occasion during the video recording he mentioned a number of past abuses and violent traumas that could have led to his death, leading him to conclude, “[I] truly have God on my side.” But this realization only led to another question: “Why is he [God] keeping you around?” Pointing to his home, Ronnie answered, “Well this is why. This is why. Cuz he knows what's inside you, and what you can put out, towards other, other life. And uh ((pause)) I know why I'm here now. Raise these two beautiful kids, and ((pause)) I know my purpose now.”
With regard to physical well-being, in the health interview Ronnie pointed out that while he “enjoyed smoking for many years,” he now appreciated that there are “so many benefits of not smoking, you know, and I lose out so much when I smoke.” Ronnie became animated when he spoke of the sensory pleasures of life without smoking. And when Melissa recounted an incident when their daughter came up to Ronnie crying about his cigarette smoking and exclaiming, “I don't want you to die,” Ronnie said that this hit him “hard,” even though he was not ready to quit at that time.
In the next excerpt, Ronnie responded to the interviewer's request that he talk more about his smoking. Melissa's responses and reactions are revealing. Although ADHD had not yet entered the conversation, Melissa drew a connection between nicotine and the type of medication often used to treat ADHD.
| RONNIE: | Sure. What do you want to know? It's a disgusting habit. There's no benefit in it other than me having a stress—a quick stress reliever. But I quit before. I could quit again. I want to quit. You have to want to quit. ((emphatically)) | |
| MELISSA: | But it's hell for everybody else. ((quietly)) | |
| RONNIE: | Only for a little bit. ((Melissa shakes head and mouths “no.”)) I got good there later on in time. ((Melissa shakes head and mouths “no” again.)) | |
| MELISSA: | It's a stimulant. Nicotine is a stimulant. | |
| RONNIE: | It is a stimulant. | |
| MELISSA: | And it kind of balances him ((pause)) in my own perspective, my own interpretation. When he's out of balance he's highly agitated and very um ((long pause)) not fun to be around, I guess you can say. And the cigarette smoking is huge on our budget, huge on our budget, but on the same token it's huge on the mental health. For him to have that balance, that it kind of balances that rest of us ((laughing)). I don't know— | |
| RONNIE: | That's really sad. That is really sad. |
Ronnie then said he would work harder to manage his agitation the next time he quit.
A bit later, Ronnie stated, “I'm ADHD,” and contrasted smoking as medication with prescribed pharmaceutical treatment:
Where she gets this balance from is I'm ADHD. My whole family is pretty much and I get really hyper, real hyper. If I'm stressed and I'm angry, I might as well be an incredible hulk. I'm just raging. And that cigarette is literally, like, becomes medication. Tried the medication thing. You know, and it's, you're like this, “Hi, how you doing.” ((spoken in a flat voice with minimal affect)) How am I supposed provide for my family like that? I'm in construction, you know. They—get off my job kid, you know. You got to be kidding me. You become an endanger to yourself.
Through putting his physical integrity at risk while on the job and jeopardizing his chances for being hired and kept on a job, it was never a viable option to take prescribed medication instead of self-medicating by smoking.
Ronnie explained that his ADHD and bipolar disorder account for his history of “drug abuse” and his proclivity to violent outbursts outside the familial context. When Ronnie initially sought help, he told the first psychiatrist he saw, “I smoke to be normal. I smoke weed to be normal or I smoke cigarettes whatever. I drink. I—whatever abuse I was doing at the time, I told her I did it because I was normal.” Ronnie sees this psychiatric consultation as failing to acknowledge his ADHD because he was told only that he was “an alcoholic drug addict.” This discouraged him from seeking further help for some time. Below, Ronnie and Melissa talk about the time he sought help again.
Ronnie discontinued taking the medication because it made him “depressed” and “dysfunctional.” Although he felt he had developed strategies to deal with his “agitated moments,” he found it depressing that he could not aspire to become a foreman because in “one moment of agitation” he might “break the customer's nose” or otherwise react in ways that would jeopardize his “leadership position” if not his job. Still, taking time off from work to see whether it was possible to stabilize the medication at an acceptable level was dismissed by Ronnie because it would entail a loss of income essential to the family's fragile financial stability. Nicotine is a “medical need” that serves its “medical purpose” by allowing him to function in everyday contexts. When Melissa suggested that counseling might help Ronnie handle anger more effectively, Ronnie resisted by countering that “it's not really that bad,” further claiming that he has come a “long way” and providing a recent example in which he demonstrated “self-control” by “walking away” from an altercation with a stranger that threatened to become physical.
Ronnie's doubts surfaced more explicitly in another conversation when Melissa was not present. He remarked, “Melissa hates it when I don't smoke,” noting that his lack of a “fuse” and his angry explosions put his marriage at risk. He admitted that he was “pretty scared about quitting smoking again.” He continued: “There was a time of ugliness. I don't know. I can try and see what happens.” Shortly afterward, he asserted, “It is a major desire for me to quit smoking. I've got my heart and mind set on it after the holidays.” The choice of time reflected his desire to keep the holidays as happy as possible for the family. While Ronnie saw the ability to stop smoking as being under his control, regulating his “agitated moments” was seen to require considerable effort, with an uncertain outcome and inevitable rough spots. The “medical need” to smoke so that he doesn't hurt someone makes his past relapse less of a personal failing. Still, Ronnie hoped for a better future: “I'm always looking for the better me.”
In the past Ronnie's quest for personal well-being through losing weight led not only to improvements in his own diet, but his family's as well. Health as a family matter went hand in hand with health as an individual matter: there was a happy convergence of the morality of the body with the morality of care for the family. Further, as a consequence of this success, Ronnie came to see himself as having the willpower necessary to sustain significant behavioral changes. The open question is whether, or how, the apparently conflictual needs of supporting both everyday family well-being and personal well-being might be reconciled should Ronnie act on his desire to quit smoking. His last attempt to renounce smoking is remembered by Melissa as a time when “everybody else” experienced “hell,” whereas Ronnie focused on the positive changes he experienced until things fell apart. For Melissa, quitting itself portends trouble; for Ronnie, the special stressful circumstances of the house purchase obligated him to resume smoking because “otherwise people were going to get hurt.” At the time of the CELF research, Ronnie's cigarette smoking, and to some extent alcohol consumption, were woven into the fabric of life in the Casey family. The credit both parents bestow on the “bad habit” of smoking for maintaining the precarious equilibrium of everyday life—by decreasing interpersonal strife and helping Ronnie to “function well every day” both at work and at home—underscores that much more is at stake than personal well-being in his determination to quit smoking.
CONCLUDING COMMENTS
With a focus on the father's smoking and drinking for two families in the CELF study, and through attention to what matters to family members in their daily lives, the material presented in this chapter revolves around the analytic challenge of understanding matters of health and well-being as embedded in an individual family's way of life. Through the lens of health as a family matter, I have sought to convey at least some of “the sense in which experience is situated within relationships and between persons.”41 Linked to compelling concerns within distinctive local moral worlds, the two families evidence variability in the way that a socially embedded and relational view of health as a family matter connects with health as an individual matter. In closing, I want to comment briefly on the way the prevailing cultural idealization of individual health promotion takes on differential meanings in the everyday lives of these two families.
While both fathers maintain that it is their children who imbue their daily round of activities with meaning, what is at stake for them in the context of everyday family life with regard to smoking, drinking, and their children differs tremendously. For Dale, it matters that his younger, medically vulnerable children not see him smoking, or at least only infrequently, so that he does not acquire the identity of being a smoker and thus offer a dangerous role model. In framing smoking, in particular, as a want rather than a need, he does not offer an accounting for his unwillingness to quit that addresses either the morality of the body or the morality of caring for family. And while Dale does not deny his responsibility for his actions and their present and possible future consequences, he advances the claim that health and well-being are also to be found in doing what one wants to do in the present, especially given the way omnipresent dangers in the world make everyone's life course uncertain. That Dale and Kelly do not regularly come into open conflict over Dale's smoking and drinking but have reached some sort of truce or perhaps stalemate was evident during a short break in the health interview when Dale expressed his surprise that Kelly had brought up issues that he thought they had settled long ago. Kelly simply replied, “This is my chance.”
Living closer to the financial edge and with a pervasive foreboding of the potential for discord and aggression, Ronnie's smoking and drinking are seen to help keep disorder at bay. The drain on the family budget is, in Melissa's view, money well spent as it buys “mental health” and “balances the rest of us.” Smoking for Ronnie is not a want but a need, and as such its role in supporting the smooth functioning of family life is evident to both parents. Ronnie's ambivalence centers on the way his self-inflicted “abuse” has been necessary for him in order to “function well” and be “normal.” As one of two breadwinners in a family in which both paychecks have difficulty stretching to meet the bills, much is at stake in the preservation of Ronnie's ability to function. Further, the abusing of self is preferable to abusing others, especially when the others are those who make your life worth living. If Ronnie's smoking and drinking are not quite moral virtues, neither are they moral failings. Yet Ronnie expresses awareness that the current state is a catch-22 because the ongoing self-abuse has the potential to lead both to his early demise and to placing the well-being of those he loves in jeopardy. He pins his hopes for the future on having enough personal strength and self-control to succeed in his quest to quit smoking in a way that would meet the demands of both the morality of the body and the morality of caring for family. Still, if he is unable to find a way to meet the demands of both, it seems likely that his familial obligation to provide for his family in the present will continue to trump his obligation to take steps to promote his personal health.
For both of these families, the economic resources needed to support the smooth running of their households and to enhance overall economic security are seen to be achieved through the joint efforts of both parents while remaining vulnerable to many factors outside their control. As smoking and quitting smoking are construed, in the end, as volitional acts, it is intriguing that the moral cast of smoking as a family matter partakes of the way smoking is seen to be intertwined with the family's financial well-being. Among other concerns, Kelly portrays Dale's smoking as a financial drain and as a potential damper on her aspirations for her children's future: ensuring the availability of economic resources that can be drawn upon to promote their children's success is an essential parental obligation (among others) in Kelly's eyes. In the Casey family, despite their somewhat tenuous financial standing given the debts they incurred purchasing and refurbishing their home, both parents expressed considerable pride in their new home and their efforts to improve it over the past year. Just as Ronnie's most recent effort to stop smoking exposed the accompanying interpersonal and economic risks associated with quitting, it revealed how his smoking played a contributory role in the family's achievement of a key marker of middle-class status, the purchase of their own home. In distinctive ways, the two cases examined disclose how viewing health as a family matter draws attention to the material underpinnings of family well-being.
Although the individual health promotion model and the notion of health as personal well-being stand as the backdrop to the sketches of health as a family matter presented here, they fall far short as conceptual cultural tools for understanding the complexity of health as embedded in everyday family life and as bound up in familial relations. While the Morris and Casey parents offer perspectives on both individual- and family-level health that reflect their unique circumstances, compelling concerns, and past experiences, what they share with other families in the CELF study are visions of health and well-being that take shape in everyday family life in concert with others.
NOTES
1. Shweder 2008, 69.
2. See, e.g., Backett 1992.
3. Weisner 1998, 76; see also Weisner 2009.
4. Cf. Mathews and Izquierdo 2009, 12, 255-57.
5. Baumeister 1991, 213. Cf. Blaxter 2004, 54-55; Izquierdo 2005.
6. Hollan 2009, 211, 224.
7. Cf. Wikan 1990; Kleinman and Kleinman 1991.
8. For additional examples of this approach, see Garro 2010, 2011; Garro and Yarris 2009.
9. Ochs and Kremer-Sadlik, this volume.
10. Adelson 2000, 4.
11. Blaxter 1997, 748.
12. Crawford 2006, 408; see also Crawford 1984.
13. Crawford 1984, 70.
14. Backett 1992; Crawford 1984.
15. Conrad 1994, 393.
16. Backett 1992, 266.
17. Blaxter 2004, 89.
18. Crawford 2004, 506.
19. Ibid.
20. Ochs, Pontecorvo, and Fasulo 1996, 9.
21. Mathews and Izquierdo 2009, 262.
22. Ibid., 261.
23. Ibid., 262.
24. Ibid., 2.
25. Thin 2009, 37, 36.
26. Mathews 2009, 167.
27. Blaxter 2004.
28. Ibid., 148.
29. Shweder 2008, 71, 69.
30. Blaxter 2004, 51-53; 1990, chap. 3.
31. Blaxter 2004, 53.
32. Ibid., 52.
33. Mathews and Izquierdo 2009, 261.
34. Crawford 1984, 62.
35. Crawford 1984; Backett 1992.
36. Saltonstall 1993, 8.
37. Mathews 2009.
38. A full discussion of these efforts is provided in Garro and Yarris 2009.
39. Garro and Yarris 2009.
40. Ochs and Izquierdo 2009, 391, 394.
41. Jackson 1996, 26.