- Explain how social factors are important for health.
- Compare the dual nature (applied and theoretical) of medical sociology.
- Account for the emergence of new infectious diseases.
The purpose of this book is to introduce readers to the field of medical sociology. Recognition of the significance of the complex relationship between social factors and the level of health characteristic of various groups and societies has led to the development of medical sociology as a major substantive area within the general field of sociology. As an academic discipline, sociology is concerned with the social causes and consequences of human behavior. Thus, it follows that medical sociology focuses on the social causes and consequences of health and illness. Medical sociology brings sociological perspectives, theories, and methods to the study of health, illness, medical practice, and policy. Areas of investigation include the social causes of health and disease, health disparities, the social behavior of health care personnel and their patients, the social functions of health organizations and institutions, the social patterns of the utilization of health services, social policies toward health, and similar topics. What makes medical sociology important is the critical role social factors play in determining or influencing health outcomes.
A major development in the study of health and disease is the growing recognition of the relevance of social determinants. The term social determinants of health refers to social practices and conditions (such as lifestyles, living and work situations), class position (income, education, and occupation), stressful circumstances, poverty, and discrimination, along with economic (e.g., unemployment, business recessions), political (e.g., policies, government benefits), and religious factors that affect the health of individuals, groups, and communities, either positively or negatively. Social determinants not only foster illness and disability, but they also enhance prospects for coping with or preventing disease and maintaining health. Once thought of as secondary or distant influences on health and disease, it now appears that social connections can be a fundamental cause of health problems (Link and Phelan 1995; Phelan and Link 2013). The social context of a person's life determines the risk of exposure, the susceptibility to a disease, and the course and outcome of the affliction—regardless of whether it is infectious, genetic, metabolic, malignant, or degenerative (Holtz et al. 2006). Thus, it can be claimed that “society may indeed make you sick or conversely promote your health” (Cockerham 2013a:1).
For example, in addressing the question of whether or not social factors matter to health, the National Research Council and the Institute of Medicine documented various links between social determinants and health (Woolf and Aron 2013). The most important
social factors determining health were found to be income, accumulated wealth, education, occupational characteristics, and social inequality based on race and ethnic group. These variables have direct effects on both unhealthy and healthy lifestyles, on high- or low-risk health behavior, and on living conditions, food security, levels of stresses and strains, social disadvantages over the life course, environmental factors that influence biological outcomes through gene expression, and other connections (Cockerham 2005, 2013a, 2013b; Daw et al. 2013; Frohlich and Abel 2014; Goodman, Joyce, and Smith 2011; Phelan and Link 2013; Phelan, Link, and Tehranifar 2010; Miech et al. 2011; Montez and Zajacova 2013; Sandoval and Esteller 2012; Woolf and Aron 2013; Yang et al. 2013).
Social factors are also important in influencing the manner in which societies organize their resources to cope with health hazards and deliver health care to the population at large. Individuals, groups, and societies typically respond to health problems in a manner consistent with their culture, norms, and values. As Donald Light (Light and Schuller 1986:9) explains, “medical care and health services are acts of political philosophy.” Thus, social and political values influence the choices made, institutions formed, and levels of funding provided for health. It is no accident that the United States has its particular form of health care delivery and other nations have their own approaches. Health is not simply a matter of biology but involves a number of factors that are cultural, political, economic, and—especially—social in nature. It is the social aspects of health that are examined in this book.
The earliest works in medical sociology were undertaken by physicians and not by sociologists, who tended to ignore the field. John Shaw Billings, organizer of the National Library of Medicine and compiler of the Index Medicus, had written about hygiene and sociology as early as 1879. The term medical sociology first appeared in 1894, in a medical article by Charles McIntire on the importance of social factors in health. Other early work by physicians included essays on the relationship between medicine and society in 1902 by Elizabeth Blackwell, the first woman to graduate from an American medical school (Geneva Medical College in New York), and James Warbasse, who wrote a book in 1909 called Medical Sociology about physicians as a unique social class. Warbasse also organized a Section on Sociology for the American Public Health Association in 1909 that lacked sociologists and was comprised almost entirely of physicians and social workers (Bloom 2002).
It remained for Michael Davis and Bernard Stern to publish books on health with a sociological perspective. Davis published Immigrant Health and the Community in 1921, and Stern's book appeared in 1927, titled Social Factors in Medical Progress. A few publications followed in the 1930s, such as Lawrence Henderson's 1935 paper on the physician and patient as a social system that subsequently influenced Talcott Parsons's important conceptualization of the sick role years later. Henderson was a physician and biochemist at Harvard who became interested in sociological theory and changed careers to teach in the new sociology department when it was formed in the early 1930s (Bloom 2002). Parsons was one of his students.
Medical sociology did not begin in earnest until after World War II, in the late 1940s, when significant amounts of federal funding for sociomedical research first became available. Under the auspices of the National Institute of Mental Health, medical sociology's initial alliance with medicine was in psychiatry. A basis for cooperation between sociologists and psychiatrists existed because of earlier research in Chicago in 1939 on urban mental health, conducted by Robert Faris and H. Warren Dunham. A particularly significant cooperative effort that followed was the publication in 1958 of Social Class and Mental Illness: A Community Study
by August Hollingshead and Frederick Redlich. This landmark research, conducted in New Haven, Connecticut, produced important evidence that social factors could be correlated with different types of mental disorders and the manner in which people received psychiatric care. Persons in the most socially and economically disadvantaged segments of society were found to have the highest rates of mental disorder in general and excessively high rates of schizophrenia—the most disabling mental illness—in particular. This study attracted international attention and is considered one of the most important studies of the relationship between mental disorder and social class. The book played a key role in the debate during the 1960s leading to the establishment of community mental health centers in the United States.
Funding from federal and private organizations also helped stimulate cooperation between sociologists and physicians in researching problems of physical health. In 1949, the Russell Sage Foundation funded a program to improve the utilization of social science research in medical practice. One result of this effort was the publication of Social Science in Medicine (Simmons and Wolff 1954). Other work sponsored by the Russell Sage Foundation came later, including Edward Suchman's book Sociology and the Field of Public Health (1963). Thus, when large-scale funding first became available, the direction of work in medical sociology in the United States was toward applied or practical problem solving rather than the development of a theoretical basis for the sociological study of health.
This situation had important consequences for the development of medical sociology. Unlike law, religion, politics, economics, and other social institutions, medicine was ignored by sociology's founders in the late nineteenth century because it did not shape the structure and nature of society. Karl Marx's collaborator Friedrich Engels (1973) linked the poor health of the English working class to capitalism in a treatise published in 1845, and Emile Durkheim (1951) analyzed European suicide rates in 1897. However, Durkheim, Marx, Max Weber, and other major classical sociological theorists did not concern themselves with the role of medicine in society, nor health-related social behavior. Medical sociology did not emerge as an area of study in sociology until the late 1940s and did not reach a significant level of development until the 1960s. Therefore, the field developed relatively late in the evolution of sociology as a major academic subject and lacked statements on health and illness from the classical theorists. Consequently, medical sociology came of age in an intellectual climate far different from sociology's more traditional specialties, which had direct links to nineteenth- and early twentieth-century social thought. As a result, it faced a set of circumstances in its development different from that of most other major sociological subdisciplines.
A circumstance that particularly affected medical sociology in its early development was the pressure to produce work that can be applied to medical practice and the formulation of health policy. This pressure originated from government agencies and medical sources, both of which either influenced or controlled funding for sociomedical research but had little or no interest in purely theoretical sociological work. Yet the tremendous growth of medical sociology, in both the United States and Europe, would have been difficult without the substantial financial support for applied studies provided by the respective governments. For example, in the United States, where medical sociology has developed most extensively, the emergence of the field was greatly stimulated by the expansion of the National Institutes of Health in the late 1940s. Particularly significant, according to Hollingshead (1973), who participated in some of the early research programs, was the establishment of the National Institute of Mental Health, which was instrumental in encouraging and funding joint social and medical projects. When Alvin Gouldner (1970) described the social sciences as a well-financed government effort to help cope with the problems of industrial society and the welfare state in the West during the post-World War II era, medical sociology was a prime example.1
However, a critical event occurred in 1951 that oriented American medical sociology toward theory. This was the appearance, in 1951, of Talcott Parsons's book The Social System. This book, written to explain a relatively complex structural-functionalist model of society, in which social systems are linked to corresponding systems of personality and culture, contained Parsons's concept of the sick role. Unlike other major social theorists preceding him, Parsons formulated an analysis of the function of medicine in society. Parsons presented an ideal representation of how people in Western society act when sick. The merit of the concept is that it describes a patterned set of expectations defining the norms and values appropriate to being sick for both the sick person and others who interact with that person. Parsons also pointed out that physicians are invested by society with the function of social control, similar to the role provided by priests and the police, to serve as a means to control deviance. In the case of the sick role, illness is the deviance, and its undesirable nature reinforces the motivation to be healthy.
In developing his concept of the sick role, Parsons linked his ideas to those of the two most important classical theorists in sociology: Emile Durkheim (1858–1917) of France and Max Weber (1864–1920) of Germany. Parsons was the first to demonstrate the controlling function of medicine in a large social system, and he did so in the context of classical sociological theory. Having a theorist of Parsons's stature rendering the first major theory in medical sociology called attention to the young subdiscipline—especially among academic sociologists. Not only was Parsons's concept of the sick role “a penetrating and apt analysis of sickness from a distinctly sociological point of view” (Freidson 1970:62), but also it was widely believed in the 1950s that Parsons and his students were charting a future course for all of sociology through the insight provided by his model of society.
However, this was not the case, as Parsons's model...