Medical Sociology and Old Age

Towards a sociology of health in later life

Paul Higgs, Ian Rees Jones

• Publisher: Routledge
• Year: 2009
• ISBN:
  9781134150748
• Edition: 1
• Topic: Ciencias sociales
• Subtopic: Estudios de desarrollo global

The nature of health in later life has conventionally been studied from two perspectives. Medical sociologists have focused on the failing body, chronic illness, infirmity and mortality, while social gerontologists on the other hand have focused on the epidemiology of old age and health and social policy. By examining these perspectives, Higgs and Jones show how both standpoints have a restricted sense of contemporary ageing which has prevented an understanding of the way in which health in later life has changed. In the book, the authors point out that the current debates on longevity and disability are being transformed by the emergence of a fitter and healthier older population. This third age - where fitness and participation are valorised – leads to the increasing salience of issues such as bodily control, age-denial and anti-ageing medicine. By discussing the key issue of old age versus ageing, the authors examine the prospect of a new sociology – a sociology of health in later life.

Medical Sociology and Old Age is essential reading for all students and researchers of medical sociology and gerontology and for anyone concerned with the challenge of ageing populations in the twenty-first century.

This book is essential reading for all students and researchers of medical sociology and gerontology.

1 Medical Sociology and Old Age

Introduction

There is a widespread consensus that we are living in an age of demographic transition where the challenges of ageing populations in Europe and North America will lead to major problems in the provision of healthcare and in the organisation of social policy (Gee 2000). Not only are individuals living longer but they are also becoming an ever larger proportion of the population when viewed against the size of younger age groups. Generational conflict over resources has long been predicted and the ‘grey timebomb’ seems to be ticking away (Thomson 1989, Myles 2002). Bryan Turner (2000) is not alone when he sees ‘the greying of the west’ as a metaphor for the way in which demographic and epidemiological transitions of the twentieth century have combined with increasing affluence to change the landscape of illness in advanced societies. The scene therefore seems to be set for disaster. However, this transition to an older population is not simply a predictable outcome of age-related decline. There is much more to the nature of contemporary ageing than can be simply read off from population statistics. What is emerging is the culmination of long-term demographic trends in the context of distinctly new circumstances. The eminent biogerontologist Tom Kirkwood ended his first Reith lecture in 2000 on the ‘End of Age’ by stating:

New scientific understanding means that we can never think of ageing in the same way again. We are at the end of the old ‘old age’. We know that we will all die one day, but this day is being pushed back further and further. Our longer lives are carrying us into new territory for which we need to plan and prepare ourselves.

We cannot afford to be complacent. If we ignore the implications of the longevity revolution and fail to plan for the radically different world that will soon surround us, then crisis will be upon us and our bright dreams of a brave old world will surely fade and die.

(Kirkwood 2001: 17)

The seeming contradiction between a world growing older and Kirkwood’s argument that today’s ageing population represent a dramatic defiance of Nature is at the heart of why we need to go beyond the consensus and view ageing in a different light. It is not that attention has not been paid to these developments. Indeed, policy makers are very interested in what might be occurring in a host of different policy areas and on both sides of the Atlantic (Aaron, Shoven and Friedman 1999; House of Lords 2005; Pensions Commission 2005; Wanless 2001). What is missing, however, is a more radical re-examination of how these changes impact on the lives of older people themselves, particularly in those social science disciplines where these changes might be most noticeable and have the greatest impact. Both medical sociology and social gerontology are approaches that have much to say about the changing nature of both health and ageing, however they have not said much about these changes. In part this may be the result of long established disciplinary foci which channel energy into specific pathways and away from topics that seem outside of their purview. It is the argument of this book that it is a conundrum that medical sociology has underplayed the issue of ageing within the mainstream of its thinking while at the same time social gerontology has, with a few notable exceptions, avoided a direct engagement with the knowledge bases of medical sociology. This is true even where the health of older people is directly addressed. In addition, a case can also be made that because of this lack of engagement, novel aspects of this transformation of ageing described above are not given their due significance but rather are interpreted in ways that reintegrate their features into already accepted paradigms.

This chapter charts the relative absence of later life from medical sociology and seeks to take the debate about this major social change forward by suggesting that it is in the social spaces of second modernity that a sociology of health in later life will find its new foundations. A sociology of later life needs to address the reality that not only has life expectancy in the UK improved significantly, but that much of post retirement life is lived in relatively good health (Schoeni, Freedman and Martin 2008). Similarly the issues surrounding the ‘somatic society’ do not disappear just because an individual is drawing a superannuation pension. The breaking down of the barriers of what constitutes health in society exemplified by terms such as ‘healthicization’ (Williams 2004) applies as much to the older population as it does to younger groups. By successfully engaging with these changes we would argue that both medical sociology and social gerontology will be more fully able to understand the impact of social changes on ageing and of changes to ageing on the social world of health. This is not just a case of special pleading for a more gerontologically aware medical sociology. Rather it is a recognition that the demographic and epidemiological transitions have more consequences than have been noted to date.

Medical Sociology Approaching Old Age

The history of medical sociology has been one of shifting boundaries which have often been reflected in what the sub-discipline chooses to call itself. Conventionally a distinction was made between a sociology of medicine and a sociology in medicine (Strauss 1957). A further division was also made between medical sociology and the sociology of health and illness, with the latter reflecting the extension of the sociological gaze from medicine to other aspects of healthcare such as the experience of illness. While these terminological disputes may reflect the growth of medical sociology as an area of study it would appear that, with respect to older people at least, old habits die hard and the gaze of medical sociology (or its reformulations) very often ignored or subsumed the older patient into a residual category. To take one example, a recent introductory text book to health sociology (Germov 2005) addresses ageing by linking it to death and dying in a chapter entitled ‘Ageing, dying, and death in the twenty-first century’. This is not an isolated case. These gaps were highlighted some time ago by Sara Arber (Arber 1994) but show little sign of disappearing.

While medical sociology has developed branches of research addressing professional interactions, patient experiences and the social epidemiology of health inequalities it has not created a subfield of the sociology of health in later life. Later life has thus tended to be marginalised in specific ways. With respect to the study of inequalities for example, rates of mortality, illness and disability are adjusted for age but until recently there has been a relative lack of interest in the experience of health and illness beyond the age of ‘preventable death’ at 65. In relation to professional and patient experiences, older patients are often ‘interesting’ largely to the extent that they are seen to be relatively passive when compared to younger age groups (Lupton 1997). In relation to an area where many of the conditions studied are age-related – chronic illness – there is a notable silence. Indeed, Mike Bury and Jonathan Gabe make reference to this absence in their editors’ introduction to The Sociology of Health and Illness: A Reader where they comment that:

much of the chronic illness literature has taken age as a given, referred to often in passing. Much research has been on young or middle aged adults but with little reference to ageing as a process or as a major contextual factor.

(Bury and Gabe 2004: 12)

To understand the lack of attention given to ageing within medical sociology it is necessary to consider the ways in which the sub-discipline developed and how its theoretical and empirical concerns have been moulded in ways that have resulted in ageing being neglected. One possible explanation might be found among medical sociologists themselves. Mike Bury (2000) in his overview of the sociology of health and illness suggests, rather mischievously, that medical sociology’s attention to areas such as childbirth, reproduction and middle age may reflect the personal concerns of researchers within the field who have not yet reached later life. However, we would argue that it is more likely that there are stronger structural forces influencing the lack of a sociological gaze on this area.

Medical sociology as a sub-discipline of Sociology emerged in the UK after the Second World War. In the USA the famous chapter 10 of Talcott Parsons’ The Social System had provided a theoretical basis for medical sociology whereas, as Margot Jeffreys (1997) pointed out, medical sociology in the UK grew out of developments in social medicine in the 1950s and the incorporation of social science into public health research and teaching. At this time Sociology, as a discipline, was underdeveloped within UK academic institutions and within existing departments little attention was given to questions of health and illness. Instead the impetus for sociological work in this area appeared to come from an eclectic mix of economists, social historians, sociologists, anthropologists and statisticians who gradually took on the collective label of medical sociologists. Nevertheless, progress in the field was patchy and resources for secure, long-term posts in medical sociology were not forthcoming. Indeed, frustrated by indifference and sometimes hostility of the medical establishment many medical sociologists (including Jeffreys) moved out of medical departments into mainstream sociology/social science departments where they were able to develop independent research and teaching activities in the field. Matters took a more positive turn following the Royal Commission on Medical Education which reported in 1968 as well as the subsequent General Medical Council recommendation that social aspects of health and illness be a core part of the medical curriculum.

The experiences of researchers like Margot Jeffreys were in marked contrast to those of medical sociologists in the USA. There the development of medical sociology occurred earlier as noted by Bloom (2002), who traces the history of medical sociology as far back as the nineteenth century citing a number of early studies addressing health behaviour and environmental influences on health and illness. In the inter-war period, for example, there were numerous monographs on social pathology tackling such ‘social problems’ as blindness, deafness, alcoholism and, significantly, old age. However, in Bloom’s wideranging history it is clear that medical sociology, as a sub-specialty with its own clear social identity, did not fully emerge until after the Second World War. Bloom refers to the influential work of Lawrence J. Henderson, whose structural functionalist approach laid the foundations for Talcott Parsons’ seminal work on the sick role. Although Marxist influenced thinkers like Bernhard Stern had opened the door for more critical Marxist accounts of medicine and healthcare the structural functionalism of Parsons became the dominant paradigm for medical sociology in much the same way as it had become the dominant paradigm for sociology as a whole in the USA. This fitted with the post-war optimism and anti-Communist thinking of the time. From 1945 onwards, the pace, volume and intensity of medical sociology research accelerated. A major impetus for the development of medical sociology in the post-war period was funding from the National Institute for Mental Health (NIMH) for investigations addressing the social aspects of mental health problems. Considerable momentum was also gained from support of private foundations, most notably The Commonwealth Fund, The Milbank Memorial Fund, The Rockefeller Foundation and the Russell Sage Foundation. From the late 1950s the creation of the section on Medical Sociology of the American Sociological Association is a key indicator of the rapid growth in the field and marked the creation of a formal professional group within the sociological academy. The focus on social psychiatry declined from the 1970s, as medical sociologists began to move into policy-oriented and health services research. The post-war paradigm however was still heavily influenced by Parsonian functionalism, but from the 1980s the influence of the women’s movement and the restructuring of the healthcare industry were both powerful influences on redirecting the focus of medical sociology. Again however, old age was largely ignored in these changes. Indeed, within the American Sociological Association two distinct and separate sections of ‘ageing and the life course’ and ‘medical sociology’ came into existence and continue to the current day.

The development of medical sociology was not merely concerned with particular topics of research. Uta Gerhardt in her Intellectual and Political History of Medical Sociology identifies four distinct but overlapping theoretical phases for medical sociology (Gerhardt 1989). As noted above the first was Parsons’ structural functionalism; the second phase was characterised by the symbolic interactionism inspired by the work of Goffman (1959); the third phase was influenced by phenomenology and the ethnomethodology of Garfinkel (1967); with a fourth phase influenced by Marxism and conflict theory drawing on the work of Zola, Illich and others. The work of Irving Zola was particularly influential in developing the concept of medicalisation and the expansion of medicine into areas of life, including ageing, that had hitherto been considered the domain of the social and even ‘natural’ (Zola 1970). Consequently for Gerhardt whilst it may be true that in the early post-war years medical sociology was dominated by epidemiology, social psychology and the sociology of the medical profession, over these four phases its theoretical basis and empirical focus were transformed.

After the 1970s, in line with the greater rationalisation of health and social services, the emphasis was much more on socio-economic and political explanations of health services delivery and the organisation of healthcare institutions. Thus, medical sociology began to move away from the traditional concerns of role analysis and perspectives on human relations. There was also a greater emphasis on policy-relevant health services research and analysis of inequalities and power. However, once again older people were generally absent from these concerns. Despite this being an expansive period there were also still concerns in both the US and the UK about the discipline being an under-labourer for government and corporate medicine (Jeffreys 1991; Bloom 2002). Today medical sociology has expanded in its aims and scope and this has led to a blossoming of academic journals, university courses, research groupings and national and international societies. Although Denny Vågero has pointed out that the discipline followed different trajectories in other European countries (Vågero 1996), the scope of medical sociology continues to expand as it addresses the rapidly changing fields of health and medicine incorporating aspects of health and development, global inequalities, transnational disease patterns and the impact of new scientific and technological developments on social relations and understandings of the body, illness and death (Shilling 1993). Perversely given its rapid development and concerns for the vulnerable and excluded and in spite of its transformed gaze, medical sociology has continued to treat old age as a separate, often peripheral category. As we shall show this lacuna is becoming increasingly difficult to maintain as the new circumstances surrounding later life start to make themselves felt not only on processes of health but on the traditional areas covered by medical sociology.

Age as a Category within Medical Sociology

Within conventional medical sociology, when it has been addressed old age has tended to be reified as a variable (age), a period in the lifecourse (retirement), or equated with illness states (old). In spite of a continual awareness about the dangers of generalisation these conceptualisations tend to lead to later life being bracketed off as a homogenous category. This leads ultimately to static understandings of what old age and ageing represent. Examples of this can be found in two major areas of concern for medical sociologists; inequality and chronic illness.

Health Inequality

With a few notable exceptions (Arber and Ginn 1993; Victor 1994; McMunn et al. 2006) studies of inequalities have tended to concentrate on the young (childhood) or those aged under 60. Interestingly the ‘Age Stratification Model’ of ageing propounded by Matilda White Riley and others in the USA during the 1970s (Riley Johnson and Foner 1972) has not generated the response that it seems it could either in America or in the UK. This is possibly because its origins were not within medical sociology or social gerontology but rather from an analytically distinct sociology of ageing. Consequently, although there is a long tradition of studying poverty in old age (Townsend 1963; Walker 1981, 2005), the extent to which health inequalities persist in later life is an area that is only now beginning to be addressed. A major part of the difficulty is that most of the research uses concepts taken from traditional health inequalities research where occupation and occupational class are taken to be important variables. This becomes more complicated in populations over retirement age where there are difficulties in measuring Socio-Economic Position (SEP) across both the lifecourse and in later life (Grundy and Holt 2001). Research now seems to suggest that inequalities in later life are beginning to converge and that this may arise as a consequence of mortality selection or survivor effects. However, the evidence is equivocal and it is difficult to untangle different effects in older populations. For example, some have argued that, after controlling for initial health status, higher levels of wealth lead to a higher probability of survival in retirement (Attanasio and Emmerson 2003). This suggests that inequalities over the lifecourse may cast a long shadow and lead to inequalities in health that persist in retirement. Analysis of the English Longitudinal Study of Ageing (ELSA) however, suggests that the length of time since labour market exit needs to be taken into account in studies of inequalities in later life (Hyde and Jones 2007). While there have always been difficulties with connecting ageing with other parts of the lifecourse it is clear to see that simple assumptions taken from theories associated with the lifecycle circumstances of older people will no longer suffice (O’Rand and Krecker 1990).

Existing studies have demonstrated a convergence in the health of those from different socio-economic positions in older age (Arber and Lahelma 1993; Arber and Ginn 1993). This is commonly explained as the result of mortality selection or survivor effects. Conversely th...