The Sociology of Health and Illness

A Reader

Michael Bury, Jonathan Gabe, Michael Bury, Jonathan Gabe

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136411083
• Edition: 1
• Topic: Medicine
• Subtopic: Health Policy

A wide-ranging collection of both classic writings and more recent articles in the sociology of health and illness, this reader is organized into the following sections:

* health beliefs and knowledge
* inequalities and patterning of health and illness
* professional and patient interaction
* chronic illness and disability
* evaluation and politics in health care. With a thorough introduction which sets the scene for the field as a whole, and section introductions which contextualize each chapter, the reader includes a number of different perspectives on health and illness, is international in scope, and will provide an invaluable resource to students across a wide range of courses in sociology and the social sciences.

PART ONE

Health beliefs and knowledge

IN THIS FIRST PART of the Reader we provide a selection of articles that will help orientate those approaching the field of medical sociology for the first time, as well as those already familiar with some of its preoccupations. These articles cover two of the basic issues confronting a sociological view of medicine, namely how lay people conceptualise health and illness, and how far these views differ from those of doctors and other experts. One of the ways this is often conceptualised is to say that lay people are concerned with illness, and doctors with disease. While this may often be the case, research on lay beliefs and knowledge, in modern societies at least, shows that there is not a clear-cut set of ‘folk beliefs’ separate from medical ideas, and that there are complex interactions between the two operating in different contexts. Research in this area provides an important window on lay ideas and actions in their own right, but also informs research covered elsewhere in this volume.

In the first extract by Herzlich, accounts of lay views of the origins of disease are taken from a study of middle-class French respondents. In these accounts – for Herzlich, ‘representations’ – of disease, the ‘way of life’ predominates, especially that linked to urban living. Stress, fatigue and exhaustion can all exacerbate underlying problems, or be the source of new disorders, and are seen to upset the balance between the individual and his or her environment. This lay ‘equilibrium’ model of illness resonates with long-standing views of illness among both lay and expert opinion dating back many centuries. In modern settings, however, issues such as environmental pollution or road traffic accidents come into the picture. On the other hand Herzlich demonstrates that lay thought also emphasises the constitution, temperament and heredity of individuals and how these interact with the environment. The value of Herzlich’s work is that it shows how complex and important beliefs about illness are to lay people in modern societies and how they touch on matters fundamental to the organisation of modern life.

In the next extract by Blaxter, this time based on a study of Scottish working-class women, a different emphasis emerges. While in Herzlich’s work lay people can be heard speaking in detail about the impact of the environment on health, here the responsibility of the individual is more in evidence. This, for Blaxter, is something of a paradox, given that public health and epidemiological research has emphasised that it is structural factors that explain poorer health among working-class groups. Little of this was in evidence in Blaxter’s study of lay views. Rather than blame the environment, urban or otherwise, the women here emphasised their own responsibility. Deprivation and poor environments in the past were recognised, but responsibility for ‘who they were’ in the present was equally strong, if not stronger. Through this qualitative study, Blaxter calls on both sociological and epidemiological research not to overestimate the relevance of structural explanations for people in everyday settings.

If Blaxter’s findings seem to reinforce individual responsibility for health (and indeed, the wider individualism of the ‘Protestant Ethic’) and Herzlich’s the role of the environment, the next extract by Davison et al. provides an anthropological view of some of the complexities at work. In this study, set in South Wales, interviews and observations of lay responses to health focused on one disorder, namely heart disease. Davison et al. show that the lay idea of the ‘coronary candidate’ confounds medical opinion. While it is clear from the study that lay populations have assimilated many of the medical and health promotion messages about heart disease – essentially those about individual risk behaviours such as fatty diets, smoking and alcohol consumption – they are combined with other equally important observations. In lay settings, the coronary candidate appears to be almost anyone, given the widespread nature of risk behaviours and such factors as being overweight. This allows for ideas of chance and fate to retain their explanatory power, and their rationality. Davison et al.’s respondents drew attention to the exceptions to the rule concerning risk behaviours. The ‘Uncle Norman’ figure was frequently cited, who, though obviously at risk, lives his life without dying from heart disease. These lay views also revealed a critical feature of the population approach to health risks and a dilemma in health promotion: the so-called ‘prevention paradox’. This refers to the situation where whole populations are persuaded to change their behaviour (e.g. consume less fat) but with no personal benefit to many of the individuals involved – for the simple reason that they would not have had a heart attack anyway. Davison et al.’s study reveals important features of expert as well as lay opinion concerning individual risk and the health of populations.

The next two contributions move the analysis of lay beliefs even more sharply away from a focus only on individuals. In Calnan’s extract on lifestyle a contrast is made between individual psychological models of health beliefs, based on ideas such as the ‘locus of control’ which emphasise feelings of control or powerlessness over behaviour, with a sociological perspective which connects beliefs with wider contextual processes. For example, Calnan emphasises that health is not always the most important aspect of daily life, and beliefs about health may only surface during times of crisis. Moreover, social and economic circumstances, rather than individually held beliefs, may constrain or facilitate certain health behaviours. As we have seen with Herzlich’s and Blaxter’s articles, social class differences may be strongly related to differences in health beliefs and behaviours, though not always in the predicted direction. Calnan attempts to reconcile work on individual beliefs and on social circumstances, by proposing a sociological approach that emphasises the meanings attached to health beliefs and behaviour and how these might be linked with key aspects of daily life, such as work.

Brown’s article on ‘popular epidemiology’ takes research on social contexts and lay beliefs one step further, to document their relationship to the emergence of collective actions. In the case of occupational or environmental causes of disease, Brown argues that lay groups are increasingly playing a key role in the shaping of both public debate and political responses. Taking the example of toxic waste contamination in the US, Brown shows how lay beliefs about deleterious effects can become the source of important campaigns to persuade governments or sue companies they believe to be responsible. Such lay involvement erodes the clear distinction between belief and scientific knowledge, which we discussed in the General Introduction to this volume. Lay campaigns over health hazards will typically involve collaboration with sympathetic doctors, scientists and epidemiologists, or challenging the science of opponents. Thus, relays between knowledge and belief occur across the lay–expert line. Brown shows how such ‘popular epidemiology’ is helping to constitute new social movements around health issues, and provides a new terrain for the study of ‘claims making’ activity in modern society.

Finally, in this first Part of the Reader, we include an extract from Parsons and Atkinson dealing with an equally important development in lay understandings of health, namely those concerning genetic risk. The focus of the study presented is on the beliefs of those affected by a particular genetic disorder, Duchenne Muscular Dystrophy. In the article the authors attempt to understand the outlook of a group of Welsh women who have been defined as having a specific level of risk in relation to this disorder. Through detailed interviews with 22 mothers and 32 daughters, Parsons and Atkinson found significant discrepancies between lay understanding of such risks and those of medical experts. Calculating risk in this disorder is complex, but the process results in a statistic for each individual, summarising her carrier status and reproductive risk. However, Parsons and Atkinson found that many of the women in the study translated their ‘risk statistic’ into descriptive statements that provided a more certain foundation for decision making about reproduction. Rather than seeing health beliefs as fixed, these authors show that health beliefs are defined and redefined on a continuous basis. However, as with other studies discussed above, the overriding concern is to maintain a sense of identity and provide ‘everyday recipes’ that can inform action in a way that medically derived expertise cannot. The need for forms of knowledge that address existential as well as scientific issues is a thread running though much of the sociological research on lay health beliefs.

Chapter 1

Claudine Herzlich

THE INDIVIDUAL, THE WAY OF LIFE AND THE GENESIS OF ILLNESS

From Health and Illness: A Social Psychological Perspective, London and New York: Academic Press, in cooperation with the European Association of Experimental Social Psychology (1973).

WHERE DO DISEASES COME FROM? How do they originate? What is involved in illness and what is involved in health? These questions arise immediately in conversations with subjects and our first task will be to analyse the answers which they give.

Anthropologists and historians of medicine are in general agreement that causal conceptions of illness – whether popular notions or medical theories – range between two extremes. On the one hand, illness is endogenous in man, and the individual carries it in embryo; the ideas of resistance to disease, heredity and predisposition are here the key concepts. On the other hand, illness is thought of as exogenous; man is naturally healthy and illness is due to the action of an evil will, a demon or sorcerer, noxious elements, emanations from the earth or microbes, for example. Medical theories can also be classified according to their view of the relations between normal and pathological phenomena. Health and illness may be considered as radically heterogeneous, like two conflicting factors within the individual, or, on the other hand, as relatively homogeneous, like two modes of vital phenomena differing only in degree.

At various periods, in different societies and in various guises, we can see the persistence of these broad currents of thought, and often their alternation. In this respect, scientific thinking, like popular thinking, seems to consist of an infinite number of variations on the same themes.

We have also found these two themes in the thinking of the subjects we interviewed, expressed in their own words. The endogenous theme is represented by the individual and his part in the genesis of his condition. The exogenous theme is the way of life of each person. We shall examine in turn the relations of each of these factors – the individual and his way of life – with health and illness, starting with the way of life, which would appear to play the more important part.

Actually, the picture which is obtained in this way corresponds to a kind of selective perception or schema of reality. In the complex world of health and illness, the subjects choose certain aspects at the expense of others, from among the variety of factors which they learn about by experience or from other sources. The relations among the elements chosen can then be classified under a few simple headings.

Way of life

The way of life to which such a preponderant role is assigned, it must be noted, is life in towns. In fact, it is life in Paris that its citizens without exception refer to.¹ When some of them describe life in the country, it is to contrast it with their habitual way of life; the country dwellers delineate the encroachment of urban aspects on country life. In this sense the two attitudes can be regarded as similar.

In both cases, the urban way of life is always associated with illness, and its influence always undesirable. Its effect can, however, be viewed in several ways; it varies in degree from simple ‘harmful effects’ to ‘appearance of an illness’. The decline in health can have various starting points. The way of life creates in the individual, or makes use of, ‘weak points’; its effects will be felt especially where resistance is least. ‘You can have a mild intestinal infection, the first signs of a stomach ulcer, slight irritation following certain food, discomfort, early symptoms resulting from a faulty way of living … your organism being less ready to resist, these minor signs grow into illness.’

Most frequently, however, the attack is a general one. The perceptible symptoms of it are fatigue, ‘nerves’ and premature ageing, which all indicate weakness and physical wear and tear. For the individual, they represent entry into an ‘intermediate state’.… which is neither illness nor health. Subjects almost unanimously describe, often vehemently, how city life produces a world of fatigue and nervous tension. Way of life and fatigue and disturbance of nervous equilibrium are, in the last resort, synonymous for the individual. ‘Paris is fatigu...