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The Changing Face of Medical Sociology
David Wainwright
- Modern medicine has brought dramatic improvements in life expectancy and the treatment of disease.
- Despite these achievements medicine is increasingly viewed with suspicion and ambivalence.
- Medical sociology not only provides an analysis of medical discourse; its promotion of social models of health and illness have influenced the development of policy and practice.
- Three social models of health and illness are introduced and critiqued, concluding with an account of critical realism.
Medicine is an enormous achievement, but what it will achieve practically for humanity, and what those who hold the power will allow it to do, remain open questions.
Roy Porter, The Greatest Benefit to Mankind, 1997
The new discourse of health
The last century brought dramatic improvements in virtually all major objective indicators of health status, at least in the developed world. Many infectious diseases have been controlled, infant mortality has fallen dramatically and life expectancy continues to increase. The so called scourges of modernity, coronary heart disease and cancer, are slowly retreating in the face of high technology medicine. Science has ameliorated many of the more troublesome problems and constraints of the human body; reproductive technologies have radically extended control over fertility; transplant surgery has enabled damaged organs to be replaced; joint replacements have made the elderly mobile again; even the outward appearance of the body can be surgically manipulated and enhanced.
Yet despite these achievements there is a widespread belief that âbio-medicineâ is a double-edged sword. Rather than celebrating the benefits of modern medicine, many fear its potency, preferring ânaturalâ or âcomplementaryâ remedies.1 Rather than focusing on how rapidly medical science can be progressed and implemented, public debate is often concerned with subordinating technological innovation to legal and ethical regulation.2 Scandals have erupted over the retention of human organs for research, and anti-vivisectionists have succeeded in placing the interests of animals ahead of those of humans.3 New developments from stem cell technology, to gene therapy, to therapeutic cloning are presented as potential threats to be reined in and governed by the precautionary principle, which insists that safety must be proven before implementation â a demand which is arguably impossible to meet.4
Ambivalence about bio-medical science has been matched by a diminution of trust in health care providers, policy makers and other âvested interestsâ.5 The authority of the medical profession has been undermined by high-profile cases of professional incompetence or criminality. Clinical expertise and professional self-regulation are constantly eroded by a pluralistic approach to medical knowledge and the imposition of a managerial structure of control. Corporate interests, such as private health care providers and particularly the pharmaceutical companies are viewed with unalloyed suspicion. Neither the free market nor social planning are seen as legitimate means of advancing healthcare policy.6
The retreat from medical science has been matched by the promotion of a putatively social model of health and illness, based on two key observations: first that health status is shaped by social factors, for example, morbidity and mortality are patterned by social class, gender and ethnic group, and second, that health has a subjective as well as an objective dimension, that is, it is about how we feel and choose to act as well as the presence of physical pathology. Both of these observations are valid, but their translation into health policy and medical practice has brought adverse consequences.
Most notably, the emergence of the social model has radically expanded the domain of therapeutic intervention. Expenditure on health care may still be dominated by hospital services, but the thrust of health policy is much more towards the regulation of behaviour and the management of subjectivity. The New Public Health movement has shifted the clinical gaze from treatment of the sick to regulation of the well. What we eat, drink and smoke, who we sleep with, how we relate to family members and friends, and the demands of working life, have all become subjects of professional advice in the pursuit of that elusive endpoint: âwellbeingâ.
The regulation of healthy bodies has been matched by a rapid expansion of psychotherapeutic intervention. Most of the Victorian asylums have been closed and their inmates decarcerated, but the reintegration of the mentally ill has been accompanied by a blurring of the boundary between sanity and madness. New psychiatric and psychological categories have emerged, such as Attention Deficit Hyperactivity Disorder, Seasonal Affective Disorder, Post-traumatic Stress Disorder, and a host of new addictions, to pathologise what were previously thought of as aspects of everyday emotional life. The severely mentally ill may have to wait to access scarce psychiatric resources, but a burgeoning army of arguably underqualified and loosely regulated psychotherapists is available to minister to the anxious and the glum.7
Taken together the New Public Health and the rise of psychotherapy have led to a significant transformation of the relationship between the individual and the state. Aspects of everyday life which were previously sacrosanct have been opened up to therapeutic scrutiny and regulation. This colonisation of the lifeworld has given momentum to a new sense of personhood which emphasises vulnerability and dependence. Health scares which emphasise the physical or emotional threat posed by mundane aspects of everyday life, such as, sunbathing, using a mobile phone, work stress, vaccination, and so on are commonly reported in the media. Paradoxically, as health has improved, stoicism and resilience have declined. Physical and mental health are increasingly viewed as fragile states which need to be defended against a growing list of social and environmental threats.
The above trends and changes constitute a fundamental shift in our experiences of health and illness and constitute the emergence of a new discourse of health. The history of medical sociology parallels this transformation.8 From the high water mark of clinical science in the post-war period, to the psycho-social model that informs much health policy today, medical sociologists have not been passive observers, simply documenting changes as they unfold, but have played a significant role in interpreting, and in some instances precipitating, change. Broader social, cultural and political forces have driven these changes, but medical sociology has often provided the crucible in which these changes are made sense of; formulating the language and analytical framework through which policy makers, professional elites and pressure groups have articulated them. Thus, many of the themes to be found in contemporary public debates about health have their origins in earlier sociological discourse; the social model of health now shared by many medical practitioners and policy makers has its origins in sociological accounts of the social causation of illness, and the critique of medical power to be found in many official reports damning clinical autonomy and calling for greater regulation of the medical profession can be traced back to the medicalisation thesis of the 1970s.9,10,11,12
The aim of this book is to explore these transformations by examining a series of key issues in the contemporary experience of health and illness from a sociological perspective. Our approach is not to see medical sociology as detached from its subject matter, but to pick up on an earlier debate within the sub-discipline,13,14,15 which recognises that medical sociology has played an active role in shaping that which it also reflects upon. A sociology of time would not begin by taking the back off a clock, but by observing the movements of the hands around the clock face and studying the social consequences of time-keeping. Likewise we begin our account of medical sociology not by âtaking the back offâ to reveal its conceptual and methodological components, but by observing the changing face of medical sociology and its consequences for how society collectively makes sense of the experiences of health and illness.
The emergence of medical sociology
Writing the intellectual history of medical sociology presents several problems. The sub-discipline has drawn on perspectives and theories from mainstream sociology, including functionalism, symbolic interactionism, Marxism, feminism and postmodernism. Different paradigms have had more or less prominence at different points in time, for instance, Parsonian functionalism in the 1950s, interactionism in the 1960s, Marxism and feminism in the 1970s and post-modernism in the 1980s. However, although this crude chronology grasps something of the changes that have occurred in medical sociology, it needs to be treated with circumspection.
First, the rise and fall of the different paradigms does not reflect a linear process of scientific progress from error and ignorance to truth and knowledge, for instance, the apparent decline in the study of the political economy of health from the late 1970s and the growing interest in the epistemology of medical knowledge from the early 1980s, cannot be explained exclusively in terms of the inadequacies of the former or the veracity of the latter. Second, mapping paradigms onto specific periods of time implies a degree of homogeneity and consensus which is hard to find in reality. Not all medical sociologists writing in the 1950s were doctrinaire Parsonian functionalists; likewise the concepts and theories of feminism have influenced medical sociology across its history, not just in the 1970s. The influence of different perspectives varies not just across time, but also between countries, sociology departments and individual writers. Third, the researchers who have contributed to medical sociology are increasingly difficult to pigeon-hole in terms of the perspective that informs their work. Not only are they often drawn from disciplines outside sociology, but few define themselves exclusively as Marxists, feminists, interactionists or post-modernists. The influence of different intellectual traditions can still be observed, but they are often invoked and synthesised pragmatically according to the research question that is being addressed. This âmix-and-matchâ approach is particularly apparent in empirical research, for example, proponents of âmixed methodsâ often combine qualitative and quantitative methods of data collection, despite the difficulty of reconciling the epistemological assumptions of naturalistic and positivist methodologies.16
Finally, while medical sociology is a product of intellectual currents and methodologies drawn from mainstream sociology and applied empirically to the study of health and illness, their significance is only apparent behind the walls of the academy, in seminar rooms and lecture theatres, publications and conference proceedings. The face that medical sociology presents to the world and, more importantly, the influence that it has had on the way in which society makes sense of and comes to understand experiences of health and illness, is not mediated through the categories and constructions of different strands of social theory, but through engagement with a much broader discourse of health, specifically through the articulation of social models of health and illness.
Social models of health and illness
The bio-medical model of disease with its emphasis on physical pathology and biological reductionism has been criticised for neglecting the social influences on health and illness. While bio-medicine has advanced over the last century, a range of other disciplines including sociology, psychology, epidemiology and economics has explored these social influences on health, providing not just a critique of the limits of bio-medicine, but a different way of understanding and addressing health and illness. This social model of health is often presented as a single unified theory; however, the range of assumptions and perspectives included under this broad umbrella is so diverse that it is more accurate to refer to several social models. No taxonomy is likely to capture all of these differences, here we have aggregated them into three broad groupings which can be identified in the literature and which have had a significant impact on the broader discourse of health: the social determinants of health; unhealthy lifestyles; and the social construction of health and illness. It should be noted that there is inconsistency and disagreement within these groupings as well as between them.
The social determinants of health
This perspective has been adopted by epidemiologists and others working in the field of social medicine. Of the social models this is closest to the bio-medical model in that it is traditionally concerned with physical pathology, but seeks to extend notions of aetiology or disease causation, beyond the identification of a pathogenic agent, such as a virus, to include social and economic factors, such as poverty, homelessness and air pollution. This approach has a long history, charting the influences of urbanisation and industrialisation on the nationâs health from the beginning of the industrial revolution.17 Central to the approach is the claim that material deprivation plays a fundamen...
