An Introduction to the Sociology of Health and Illness

Kevin White

• Publisher: SAGE Publications Ltd
• Year: 2016
• ISBN:
  9781473994492
• Edition: 3
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

"An accessible and highly readable introduction to the Sociology of Health and Illness through the inclusion of key theorists, concepts, and theories, with reference to contemporary health concerns and recent relevant research." - Kylie Baldwin, De Montfort University "Guides us through the many reasons for the centrality of health, showing clearly that health and illness are the products not just of our biology but of the society into which we are born...an authoritative analysis of the social nature of health." - Ray Fitzpatrick, University of Oxford This bestselling text introduces students to the core principles of the sociology of health, demonstrating the relationship between social structures and the production and distribution of health and disease in modern society. Written with a truly sociological and critical perspective, the booktackles themessuch asclass, gender and ethnicity, and engages witha range of theories and theorists, including Foucault, Fleck, Parsons, Weber, and Kuhn. Thethird edition has been thoroughly updated to include the latest cutting-edge thinking in the area, with new empirical examples, updated references, and new sectionson ?Thought Styles after Fleck', and 'Transformations of the Medical Profession.? It alsouses helpful learning features including chapter overviews, case studies, summaries and further reading suggestions, to providestimulating and thought-provoking exercises for students in health, nursing and sociology schools.

1 Introduction

• Diseases are socially produced and distributed – they are not just a part of nature or biology.
• The key variables shaping the production and distribution of diseases are class, gender and ethnicity, and the ways in which professional groups define conditions as diseases.
• Medical knowledge is not purely scientific, but shapes and is shaped by the society in which it develops.
• Sociologists, depending on their model of society, develop different explanations of the social shaping and production of disease. Marxists emphasize the role of class; feminists the role of patriarchy; Foucauldians the way society is administered by professionals; and those focusing on ethnicity, the impact of racism.

Sociologists study health and illness not only because they are intrinsically interesting, and go to issues at the centre of human existence – pain, suffering and death – but also because they help us to understand how society works. For sociologists the experience of sickness and disease is an outcome of the organization of society. For example, poor living and working conditions make people sicker, and poorer people die earlier, than their counterparts at the top of the social system. Even when there are improved living conditions and medical practices, but inequalities based on class, gender and ethni-city are not tackled, the differences between the rich and the poor persist and widen. Disease and inequality are intimately linked. The outcome of the unequal distribution of political, economic and social resources necessary for a healthy life is the social gradient of health. Those at the top of the social system are healthier and live longer while those at the bottom are sicker, do not live as long, and die more from preventable disease and accidents. These links between social factors and health and disease are the focus of this book.

This book demonstrates the relationship between social structures and the production and distribution of health and disease in modern society. Specifically, it examines the impact of class and the role of the medical profession, gender and ethnicity on the production and distribution of disease. It argues that there is no simple relationship between biological and individualistic explanations of what causes sickness and disease. Furthermore it demonstrates that medical knowledge is not disinterested, objective, scientific knowledge, but is both shaped by and shapes the social structures within which it is embedded. Following some scene setting for the principles of the sociology of health, and of the social and political climate that is shaping our understanding of the causes of health and disease, the book reviews Marxist, Parsonian, feminist and Foucauldian approaches to health, as well as examining the data on the impact of ethnicity on health.

In modern Western societies it is usually assumed that health differences are biologically caused or that individual lifestyles result in people becoming sicker and dying earlier. The argument of this book is that there is little evidence that disease is caused by purely biological factors, operating separately from social organization. It is also the argument that individual lifestyle choices are socially shaped, and that a focus on them as an explanation of the cause of disease misses the social factors involved in producing individual actions. Rather, there are a wide range of mediating social factors that intervene between the biology of disease, individual lifestyle, and the social experience shaping and producing disease. These range from standards of living and occupational conditions, to socio-psychological experiences at work and at home, of men’s and women’s social roles, and of hierarchical status groups based on ethnicity. These factors, in turn, have to be seen against the background of the overall patterns of inequality that exist within specific societies. This includes whether or not there is a political commitment to reducing inequality and providing a social environment that prevents sickness and disease – of guaranteeing housing standards, food standards and conditions of employment, as well as enhancing lifestyles that increase health and longevity. Put simply, the impact of income inequality now appears to be central to the continued existence of inequalities in health. As Wilkinson (1996) has shown, countries with low relative differences between the richest and the poorest are the healthiest.

Sociology, Genetics, Social Mobility and Lifestyle

Sociologists argue that our understanding of the social production of disease is not helped by explanations:

• that focus solely on genetics at the expense of the social environment;
• that claim that the sick are poor because they experience downward social mobility;
• that fail to recognize that lifestyle choices are shaped by social factors.

In our daily life, three dominant representations of the causes of disease, especially in the media (the newspapers, medical docudramas and TV soaps), stand out. The first of these is the genetic explanation. Genetic explanations regularly feature in articles and programmes in which claims are made that there is a genetic cause for obesity, drug addiction, alcoholism, divorce and homosexuality, to mention just the most common. There is, however, no evidence for a genetic contribution to what are cultural practices, nor any scientific justification for the negative moral evaluations of them that are couched in the language of medical science. These conditions are clearly culturally specific and professionally defined – not ‘facts’ of nature. Furthermore, there is little that can be done about even those diseases for which there is genetic evidence for their origins. Short of undertaking a eugenicist or genetic planning experiment, the knowledge of genetic predisposition does not help either individuals or policy makers to deal with disease. In fact, by reducing the explanation of the individual’s condition back to a lowest common denominator of biology, the genetic explanation systematically excludes a sociological explanation, and functions to deflect our attention from the ways in which social life shapes our experience of disease. Between the genetic predisposition for a specific disease and its development lie the intervening variables of politics, economics, gender and ethnicity. It is these variables that must be taken into account in explaining the transformation of a ‘genetic risk’ into a social reality.

A second common assumption is that the sick experience downward social mobility, while the healthy experience upward social mobility. This is an extension of what is presumed to be Darwin’s argument about the survival of the fittest. There is no support for this argument in the literature. The sickest are certainly in the poorest sections of society, but they are sick because they are poor, not poor because they are sick. Where sickness and downward social mobility intersect, it is in those conditions where political, cultural and social practices already discriminate against the individual – the single mother, the disabled, the differently coloured and those with AIDS.

The third dominant explanation for the existence of disease, in what should otherwise be healthier societies, is that people adopt a lifestyle that makes them sick, and are therefore individually responsible for their condition. The lifestyles explanation claims that freely made bad choices about diet, smoking and exercise make people sick. Again, there is very little evidence that individual effort at this level will achieve much in the way of a healthier society. Moreover, all the major studies, brought together in this book, show that good lifestyle choices are overwhelmed by wider structural variables in determining health and illness. Lifestyle actions do not account for more than a minor part of the variation in health status. Even if they did, since they are unevenly socially structured rather than individually chosen, they are the outcome of inequality rather than the cause of it.

For sociologists of health these three explanations have two common features. They make the claim that when individuals become diseased it is a problem of the individual’s own body and of their unique biology. Put another way, these explanations individualize and biologize the explanation of disease. Often they are combined into explanations that blame individuals for lifestyle choices that they are biologically incapable of coping with, because of their genetic make-up. This ‘over-determined’ individual and biological explanation is very common in societies based on racialized status groups.

Box 1.1 Aboriginality, Lifestyle And Genetics – Obscuring Social Processes

In Australia, it is claimed that Aboriginal people have higher rates of diabetes because they freely choose bad Western foods such as potato chips, soft drinks and alcohol, for which they are genetically not ‘programmed’. Thus their health problems read as the following equation. They choose poor foods (therefore it is their fault) + they are genetically not capable of processing Western food (the fault of their individual biology) + they are lazy or indifferent about their health (the fault of their culture). The conclusion, which policy makers informed by this way of approaching the problem then reach, is that it is the Aborigines’ problem that they are sicker and die sooner, and that there is little or indeed nothing that can be done about it.

A sociological account, on the other hand, directs attention to the political and economic shaping of lifestyles available to subordinate populations, and to the way in which racism systematically destroys the beneficial aspects of an indigenous population’s culture.

The Sociological Perspective

Sociologists, on the basis of empirical research, demonstrate how the interactions of class, of professional interests, of power, of gender and of ethnicity enter into the formation of knowledge about and treatment of a sickness or disease. They demonstrate the social production and distribution of diseases and illnesses. Sociologists show how diseases could be differently understood, treated and experienced by demonstrating how disease is produced out of social organization rather than nature, biology, or individual lifestyle choices. While sociologists make no claim to being biological scientists they do make the claim that biological knowledge can be sociologically explained, to show that our knowledge of health and disease is created in a political, social and cultural environment. There is no pure, value-free scientific knowledge about disease. Our knowledge of health and illness, the organizations of the professions which deal with it, and our own responses to our bodily states are shaped and formed by the history of our society and our place in society.

Since sociologists do not accept the medical model of disease and illness as simply biological events, they then examine the social functions of medical knowledge. That is, they examine the way medical and biological explanations of disease function in our society. Medical knowledge is produced in and reflects structural features of society. It explains as ‘natural’ what, from a sociological perspective, are social phenomena. Why the working class is sicker and dies earlier, why women are diagnosed sick more than men, and why ethnic groups do not receive the services they need – these require a sociological explanation and not a biological one. Medical explanations obscure and paper over the social shaping and distribution of disease, disease categories and health services.

Postmodernity and Sociology

The arguments of the sociologists of health are particularly important in the current economic and political climate. There has been a major restructuring of the labour market in the Western capitalist economies, with a decline in industry and, associated with this, of trade unions and class-based political movements. There has been a resurgence of the philosophy of liberalism – that the state should not be involved in the provision of welfare services, and that individuals should take more responsibility for their own lives. The economic changes are sometimes summarized in the term ‘postmodernity’ – that we have moved beyond organized capitalism, and into a new era in which consumption rather than production is the key to social life. Some sociologists have celebrated these changes. The claim is that we now live in a postmodern world, freed of the old structures of industrial capitalism and the bourgeois nuclear family. For Ulrich Beck, these changes mean that people ‘will be set free from the social forms of industrial society – class, stratification, family [and] gender status’ (Beck, 1992: 87). Identity has become fluid and negotiable, separated from ‘social structures’, which are now claimed to be just a figment of the sociological imagination. For some theorists the discovery of the body, linked to these weakened structures, has led to the argument that we construct our bodies as we see fit. Anthony Giddens, for example, emphasizes the openness of the body, and of individuals to shape it: ‘We have become responsible for the design of our own bodies’ (Giddens, 1992: 102). Similarly, Bauman (1992) has argued that both our sociological knowledge and the world that we live in are uncertain, ambivalent, deregulated and insecure. The stable basis of our identity has gone, as have the certainties of social science knowledge. At the core of these changes, according to Bauman (1998), is a transformation from a culture of production, in which hard work, thrift and self-discipline held sway, to a world of hedonistic indulgence. Rather than hard work resulting in savings and social prestige, we are rewarded with ‘free sex’, designer drugs and ‘life in the fast lane’.

Box 1.2 Modern Society May Have Changed – But Key Social Structures Persist

It is the argument of this book that there is little evidence that social structures of class and gender, of ethnicity and of inequality have stopped shaping people’s lives. Industrial capitalism may have changed its appearance, and patriarchy may no longer be the bulwark of women’s oppression, but they both still structure health and illness, and distribute disease unequally through the population. In the area of health and illness individuals have not been freed from the structures of patterned inequality, nor have their choices increased. In fact, society has become more unequal, and the poor sicker.

Sociological Approaches to Health and Illness

Different sociological perspectives on society give rise to different accounts of the role of medical knowledge, and of the social causes of disease. They are also based in different sociological models of society, in part complementary, in part contradictory. Marxist approaches emphasize the causal role of economics in the production and distribution of disease, as well as the role that medical knowledge plays in sustaining the class structure. Parsonian sociology emphasizes the role of medicine in maintaining social harmony, pointing to the non-market basis of professional groups. At the same time, its critical sociological edge is maintained by the way it highlights the social control function of medicine in enforcing compliance with social roles in modern society. Parsons’ work both contradicts Marxism – by highlighting the importance of the non-economic sphere of society – but also adds to it in providing a description of the sick role as a social role that is shaped by the social strains of modern society. Thus Parsons is both conservative and critical at the same time.

Foucault, too, highlights the social role of medical knowledge in controlling populations, and like Parsons emphasizes the diffuse nature of power relationships in modern society. Also, like Parsons, he sees the professions, especially the helping professions, playing a key role in inducing individuals to comply with ‘normal’ social roles. For Foucault, modern societies are systems of organized surveillance with the catch being that individuals conduct the surveillance on themselves, having internalized ‘professional’ models of what is appropriate behaviour. Marxist feminists identify the ways in which class and patriarchy interact to define the subordinate position of women in society and the central role that medical knowledge plays in defining women as childcarers and housewives. Foucauldian feminism, on the other hand, is more alert to the ambiguities of women’s roles, and the way that women can challenge their medicalization. However, on balance, medical kn...