The Sociology of Health and Healing

A Textbook

Margaret Stacey, Professor Margaret Stacey

• Publisher: Routledge
• Year: 2003
• eBook ISBN: 9781134897926
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

"...It is well-written and well-referenced...this is an important, innovative, enjoyable textbook which can be highly recommended for use in undergraduate and postgraduate sociology courses on health related subjects, and which will be of value in courses on women's studies and gender. It will also be of interest to inquiring health care practitioners of whatever persuasion." - Sociology "This book takes a bold step in pointing new directions for sociological and social-historical studies of health and health care." - Social History of Medicine Throughout the book, the division of labour in health care, especially as it relates to social class and gender divisions, is taken as central. Its particular characteristic, and one that distinguishes it from other texts in this field, is that feminist critiques of health care are considered alongside the mainstream writing in the social history of medicine, and in medical sociology. Part I takes an historical approach to the types of healing knowledge, the modes of treatment, and the organization of health care found in Europe over the last four hundred years. Part II is a sociological analysis of contemporary health care covering concepts of health and illness, the organization of the National Health Service, the division of labour, the impact of international capitalism, and the issues at stake in arguments about human reproduction.

1
Introduction: Some Theoretical and Methodological Thoughts

This book sets out to look at the arrangements that are and have been made at different times and places for restoring and maintaining health and for ameliorating suffering, paying particular attention to biomedicine in advanced industrial societies and most specifically in Britain. The intention is to treat these phenomena, including the associated medical knowledge, as socially created. The book is written not only for those who are teaching or taking specialist courses in the sociology of medicine or the sociology of health and illness but for sociologists and social scientists more generally. The ways in which a society copes with the major events of birth, illness and death are central to the beliefs and practices of that society and also bear a close relationship to its other major social, economic and cultural institutions. In particular, the treatment of those who are temporarily or permanently dependent on others is a revealing indicator of the social values lying behind the allocation of material and non-material resources. This being so, understanding the beliefs and practices associated with health and healing and the social processes involved contributes to a deeper understanding of the society in which they are found.

It is also the case, as I shall argue later, that the nature of health work presents particular problems for sociological analysis. Work in this area therefore has important implications for sociological theory beyond the theory required for the analysis of the substantive area itself. There are by now a number of texts for doctors, nurses, health administrators and others associated with health care (for example, Armstrong, 1980 and 1983a; Dingwall and McIntosh, 1978; Maclean, 1974; Patrick and Scambler, 1982; Tuckett, 1976). There are fewer British volumes which discuss health and healing specifically sociologically (Cox and Mead, 1975; Doyal with Pennell, 1979; see also, from the USA, Coe, 1970; Jaco, 1979; Maykovich, 1980; Mechanic, 1978). This work seeks to add a further contribution to the latter. At the same time it is hoped that this book may also be of interest to health-care practitioners and administrators who already have some interest in understanding more about the social aspects of their work. While inevitably the book will contain technical arguments and will therefore necessarily use language in a technical sense, the aim is to write in a way which is accessible to specialists in other disciplines and to an interested lay readership.

THE THEORETICAL APPROACH

Three assumptions underly the theoretical position adopted here. The first, already mentioned, relates to the social construction of all healing knowledge; the second, associated with this, is that health knowledge and practice cannot be seen simply as cultural phenomena but are related to the social and economic structure of the society in which they are found; the third assumes a common, but variable, biological base of which account must be taken. The assumption that health knowledge is socially constructed applies equally to sophisticated knowledge developed and learned in medical schools and to unwritten folklore and practice passed from generation to generation. No assumptions are made about any ultimate or absolute knowledge. The book, therefore, rests upon the assumption that, while quite different from our own, the beliefs and practices of non-industrial peoples are in their own terms logical and rational, as were those of our own people at an earlier period; also, that the beliefs and practices of lay members of our own society, although sometimes at odds with the understanding and advice of medical experts, also have their own logic and rationality. All these various notions are as much to be respected as the understandings of highly trained medical personnel. Associated with this it is also assumed that there can be no simple judgement of what is ‘efficacious’ in healing practice. Supplementary questions have to be asked such as: ‘Efficacious in whose terms? For what purpose? To what end?’

HEALTH IN THE SOCIAL AND ECONOMIC STRUCTURE

The second theoretical assumption is that health knowledge and health practice cannot be understood in cultural terms alone, although it is clearly the case that the relationship of health knowledge to other facets of the culture is important and must be explored. Reference has also to be made to the more material aspects of the societies in question and to structured social relations, particularly relations of mating, procreation and child rearing, economic relations and those associated with the political order. That is to say, it is assumed that the knowledge and practices of members of any society about how to promote, maintain and restore health will be related to and vary with these three major and fundamental sets of relationships: those to do with the reproduction of the society; with the mode of production and distribution of goods and services; and with the maintenance of internal order and external defence. For advanced industrial societies this means that three facets will be crucial: the familial or kinship structure and the associated gender order; the mode of production and the associated social and economic class system; and the various structures of the state.

This relationship, between health knowledge and practice on the one hand and the society in which they are found on the other, is not assumed to be simply one way. It is true that the division of labour in health care can in some sense be said to mirror that of the society as a whole. But it does more than that. The way health work is undertaken plays a part, sometimes a major part, in the creation and re-creation of the society itself. Clearly the beliefs and feelings about such matters as birth, mating, death and suffering which are constantly purveyed by the health carers are critical to the way the society goes about other tasks that are performed.

THE BIOLOGICAL BASE

As much as it is important to stress the social, cultural and economic concomitants of health practice and health knowledge, so it is also important to acknowledge the biological base. The assumption made here is that this base is common to all human beings. Birth, mating, ageing and death are biological phenomena; health knowledge and practices develop in response to them and to the suffering which appears to go along with living. In an attempt to avoid biological reductionism many sociologists have paid too little attention to these underlying physical phenomena, although this tendency is beginning to be overcome (see, for example, Barrett, 1981, pp. 338–9; Strong, 1982; Timpanaro, 1980; U 205 Open University Course Team, 1985a).

What this book seeks to bring out is that the same biological phenomena can be interpreted differently in different times and places for social, economic, or cultural reasons. Such interpretations and the beliefs and actions to which they lead are what I have referred to as social construction. The particular social construction of this kind with which readers will probably be most familiar is the dominant mode of the twentieth century, namely, biomedicine. I use the term ‘biomedicine’, following Kleinman (1978), to describe what is sometimes referred to as ‘modern medicine’ (a meaningless phrase because what is modern today is ancient tomorrow) or as ‘Western’ or ‘scientific’ medicine. Biomedicine indicates the predominant emphasis of that form of knowledge which is above all focused on the body as a biochemical organism.

In addition to the varied interpretations of the biological base, there is also variation in the biological base itself above and beyond the commonly shared humanity. Empirically the risks to which humans are exposed vary considerably over time and space. In some societies today—as was true in our own in times past—the expectation of life is about 25 years, and to live to 45 is to be old and therefore also to be judged wise. For example, Lewis (1975, p. 67) quotes demographic data which show that in the Sepik society of which the Gnau are a part (see Chapter 2) the population histogram forms a broad-based pyramid, ‘a form which reflects the high mortality of infants, and the greater risk there of dying in early or middle life compared to the risks in a country like England’. When they were born, men could expect to live slightly less than 45 years; at 5 years of age their expectation was nearly 48 years. Unlike England today the expectation of life of women at both ages was slightly less than that of the men, although there were slightly more women than men in the oldest age groups. In such societies there are many more children than adults, in contrast to advanced industrial societies with their increasingly large populations of the old and very old and small numbers of children and young people. Societies where epidemic diseases are rife, where flood and famine take a toll, have different survival problems from industrial societies where people are faced with heart disease and cancer. These factors, along with the inevitability of ageing and death following birth in whatever society one lives in, have to be taken into account. They form a major part of the material base upon which ideas and arrangements for health maintenance and restoration are constructed.

To make such assumptions, as is done here, is quite different from espousing a sociobiologism which implies that social life is determined biologically. Such a determinism is rejected here. The notion that the biological organism is separate from its environment is one which has developed since the Enlightenment; it is associated with endless and unrewarding arguments about ‘nature’ versus ‘nurture’. Steven Rose and his colleagues (1984) have argued from biological evidence against the correctness of this division, suggesting that organism and environment are one unitary phenomenon, each being unable to exist without the other. This argument thus surpasses those which suggest organism and environment interact and moves far beyond any notion of biological determinism.

The focus of this book, however, is the social. From this stance the rich variety of human life suggests a series of social variations upon the biological base which make biological determinism improbable. Saying that, however, is not to deny that the kinds of society we invent and particularly the way we handle issues of life, health, suffering and death arise from the way, in different societies, we perceive this essential part of our humanness. And how we perceive it, how we behave in relation to the biological base, also affects our destiny as social beings, for there is no doubt about the social creation of illness and suffering as well as the social construction of the knowledge about it.

WHAT IS HEALTH WORK?

Thinking about these theoretical assumptions makes it plain that the question ‘What is health work?’ does not have a straightforward answer; it is problematic. It is problematic partly because concepts of ‘health’ or ‘well-being’ are also problematic. In our own society health tends to be defined as the absence of organic disease, but we also have other notions of ‘being well’ and are aware of difficult problems where ‘illness’ and perhaps especially mental illness are not associated with organic disease processes. As we shall see in Chapter 2, in many societies the definition of health is wider; suffering of the body is not clearly distinguished from suffering of the mind, nor is the suffering of a group—as, for example, from flood or drought—always seen as different from individual suffering as we see it. Misfortunes of all kinds are seen in different societies in different relationships to each other. Furthermore, as Chapters 10, 11 and 12 show, in our own society health and illness are conceptualized somewhat differently in different sections of the population, and not only between the trained and the untrained.

For the purposes of analysis in this book, health work will be defined as all those activities which are involved in:

1. the production and maintenance of health;
2. the restoration of health;
3. the care and control of birth, mating and death;
4. the amelioration of irreparable conditions and care of the dependent.

Health is here being thought of in terms of general physical and mental well-being, remembering that the specification of what this is will vary over time and space, as has just been indicated.

WHO ARE THE HEALTH WORKERS?

Looking at health work in these basic sociological terms shows at once that it is a continuous activity. It also becomes clear that everyone is involved in some aspect of health work. In consequence, when thinking about the division of labour in health care we are thinking about how health-care activities are divided among the total membership of the society. In some societies it is a question as to whether there are any health specialists at all (see Chapter 2). In other societies, such as advanced industrial societies and in the ancient civilizations such as India and China, there is a highly elaborated division of labour. But we must beware that in consequence of this we do not exclude some important health workers simply because they have not had an elaborate training. Specialists may well be involved, but so are many others.

Many studies in the past have concentrated upon those who are paid for their work in a narrowly defined health-care sector. This book takes a different approach. Whether the society is simple or complex, all those who are involved in health care are taken into account. Ignoring this precept has had the consequence in analyses of advanced industrial societies of distracting analytical attention from the unwaged workers—most often mothers, wives and daughters—although, as we shall see (Chapters 7 and 16), official policy has often relied heavily upon them.

Health production activities begin with the birth of children and maintenance activities with their rearing. Our own care of our bodies and of our life-style is part of health maintenance work. Most important for health production are the activities of the food getters and the food preparers. In highly differentiated societies the former has become a major industry and the latter rests heavily on the activities in the home of those who care for the household, predominantly unwaged women in most societies. Others of their activities, such as cleansing and caring for household members, are also crucial for health maintenance.

As will emerge in the discussions of the historical development of healing knowledge and the organization of practice, a division has been made between curative and preventive services in the health conceptions of those societies where biomedicine dominates. The preventive services are really simply a negative way of looking at production and maintenance of health and one which has originated from the diseaseoriented approach to medical knowledge which is at the heart of biomedicine. Using the definition of health work adopted here, it is clear that the entire membership of the society is involved; in market economics this means the unwaged workers in addition to the paid specialists and their waged supporters. In the analysis of the restorative or curative services in such societies all the unpaid workers who help the patient through illness or accident have to be included in the division of labour along with the highly trained salary or fee earners and the waged workers who provide support services. This is also true with regard to the care of the chronic sick and disabled. There are those who are more frequently involved in unwaged health care than others. These are most often women (see also Stacey, 1984).

HEALTH WORK IS ‘PEOPLE WORK’

A large part of health work, particularly the restorative and ameliorative aspects, but also some of the maintenance activities, involves one person or groups of people doing things to or for others (Hughes, 1971). It is ‘people work’ or ‘human service’. It is from this that concepts like the division between professional and client, between doctor or nurse and patient, have become current in societies with highly developed divisions of labour. As biomedicine has developed on a mass scale, health care has come to be looked upon as an industry with the paid workers as ‘producers’ and the patients as ‘consumers’.

Consistent with earlier work (Stacey, 1976), in the analyses which follow I shall consider all those ideas as historically and socially specific to particular societies at particular times. The underlying phenomenon is that the patient is an actor in the healthcare enterprise rather than a passive recipient of care.

PATIENT AS HEALTH WORKER

Not only is the patient a social actor but s/he is a health worker in the division of health work. This has already become clear as far as the work of health production and health maintenance is concerned. It is also so as far as restorative and ameliorative health work goes. Everett Hughes recognized this as long ago as 1956 (Hughes, 1971). A ‘patient can be said to be a producer as much as a consumer of that elusive and abstract good health’ (Stacey, 1976, p. 194).

Everett Hughes’s proposal that the patient should be included in the division of health labour flowed from his observations of interactions in health care. Working in the symbolic interactionist tradition, Hughes was not trammelled by preconceptions as to the structure of the social relations he was observing, nor was he seduced by the values of the professional workers involved. He reported what he and his associates saw and he saw that patients were workers. He did not however to my knowledge expand at any length upon the theoretical implications of his observation that the patient is a worker in the division of labour. Nor have others taken up and developed his point. Even so, his pupils have continued to work in the spirit of that observation wherein the patient is a central actor in the analysis and one whose actions and values are crucial to those of the trained health-care workers (for example, Fagerhaugh and Strauss, 1977; Roth, 1963).

An altogether different approach is to think of health work as analogous to industrial production. This model I reject, although it is true that such large-scale organizations as hospitals have to be organized in a way which may be said to be analogous to the organization of a factory or a bureaucracy. The production of the ‘illusive good health’ is quite unlike the production of material goods; health cannot be compared to a can of peas or to the factory-made pins of which Adam Smith wrote. The trained workers, the relatives and friends, the patient her/himself are working together (more or less cooperatively and with more or less mutual misunderstanding) on the mind or body of the patient. This is a qualitatively different activit...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Figures
• Preface
• Acknowledgements
• 1: Introduction: Some Theoretical and Methodological Thoughts
• Part One
• Part Two
• References and Bibliography