The Sociology of Health and Illness
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The Sociology of Health and Illness

Sarah Nettleton

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eBook - ePub

The Sociology of Health and Illness

Sarah Nettleton

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Sarah Nettleton's The Sociology of Health and Illness has become a cornerstone text, popular with students and academics alike for its rigorous and accessible overview of the field. Building on these strengths, the fourth edition integrates fresh insights from the current literature with the core tenets of traditional medical sociology, providing students with a thorough grounding in the sociology of health and illness.

The text covers a diversity of topics and draws on a wide range of analytic approaches, spanning issues such as the social construction of medical knowledge, the analysis of lay health beliefs, concepts of lifestyles and risk, the experience of illness and the sociology of the body. It also explores matters that are central to health policy, such as professional–patient relationships, health inequalities and the changing nature of health care work. A new chapter has been added, on the sociology of mental health; other chapters have been updated with illustrative examples and questions for discussion.

Written for students of the social sciences, this book will also appeal to students taking vocational degrees, such as nursing, medicine and public health, who require a sociological grounding in the area. Thoroughly revised and fully updated, this fourth edition will prove invaluable to anyone looking for a clear and engaging introduction to contemporary debates within the sociology of health and illness.

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Introduction: The Changing Domains of the Sociology of Health and Illness


Sixty years ago, the mention of health and illness would probably have invoked thoughts of hospitals, doctors, nurses, drugs and a first aid box. Today, however, it would probably conjure up a much broader range of images, which could well include healthy foods, vitamin pills, aromatherapy, alternative medicines, exercise bikes, health clubs, aerobics, walking boots, running shoes, therapy, sensible drinking, health checks and more. Health, it seems, has become a ubiquitous cultural motif in neoliberal settings. Health and illness receive considerable attention from the media: television, radio, newspapers, magazines and videos all devote considerable space and time to health-related issues. Information and knowledge about health and illness are thus recognized as no longer just the property of health ‘experts’. Everyone has at least some experience and knowledge. This book is about the contribution that sociology can make to contemporary understandings of health, illness and the human body.
Although many of the concepts dealt with in this book may have rather grandsounding names, they all attempt to come to terms with issues and experiences that will be familiar to many readers. The sociology of health and illness is not confined to the narrow domain of the formal institutions of medicine. It is concerned with all those aspects of contemporary social life that impinge upon well-being throughout the life-course. To understand those aspects of social life that impinge on health, we must attend to the mundane practices of day-to-day life, to the norms, the values and expectations that shape our identities, to the local, national and global institutions of health and welfare, and to the processes of globalization and colonialization that engender inequalities in health. The trick is to try to appreciate how these dimensions weave together, to place individual lives in wider histories.
From before the moment that we are conceived to the time that we die, social processes impinge upon our health and well-being. The social locations of our parents will affect our life chances. Our birth may be mediated by technology and controlled by health professionals. The beliefs about health and illness held by our peers and by those with whom we live will shape our own experiences and understandings. Our contact with health professionals (dentists, doctors, pharmacists, opticians, health promoters, practice nurses and so on) is likely to become a routine fact of our lives. Our self-identity may be shaped by our experiences of illness and our interactions with both formal and informal institutions of health care. Our attitudes towards our bodies will be influenced by the discourses of health promotion and consumer culture. Our experiences of death and dying will be affected by our sociocultural context. We may come into contact with new technologies of health care, for instance through our own illnesses or through having children. We may have to face the ethical and moral dilemmas central to the blurring of the beginning and ending of life. We may work in organizations either directly or indirectly associated with health work. We will all carry out some form of health work, which may involve caring for elderly relatives, children, partners or friends, and, of course, ourselves. It is the sociological analysis of topics such as these that provides the basis for this book.
The development of the sociology of health and illness has to be understood in terms of its relation to the dominant paradigm of Western medicine: biomedicine. Many of the central concerns of the sociology of health and illness have emerged as reactions to, and critiques of, this paradigm. This introductory chapter briefly outlines the main features of biomedicine and some of the main challenges that have been made against it. The history and the main theoretical underpinnings of the sociology of health and illness are also briefly considered, in order to provide a contextual backdrop to the rest of the book. The chapter concludes by highlighting the centrality of shifting conceptualizations of the body in both contemporary medicine and sociology – a theme that recurs at various points throughout the text. We shall see that just as the social and cultural parameters of health and illness have shifted and broadened, so too have the domains of their sociological study.

Medicine and the Biomedical Model

Modern Western medicine rests upon what has become known as the biomedical model. This model is based on six assumptions. First, that the mind and the body can be treated separately; this is referred to as medicine’s mind/body dualism. Second, that the body can be repaired like a machine; thus, medicine adopts a mechanical metaphor, presuming that doctors can act like engineers to mend that which is dysfunctional. Third, and consequently, the merits of technological interventions are sometimes overplayed, which results in medicine adopting a technological imperative. Fourth, biomedicine is reductionist, in that explanations of disease focus on biological changes to the relative neglect of social psychological and political factors. Fifth, such reductionism was accentuated by the development of the ‘germ theory’ of disease in the nineteenth century, which assumed that every disease is caused by a specific, identifiable agent – namely a ‘disease entity’ (such as a parasite, virus or bacterium). This is referred to as the doctrine of specific aetiology. Finally, this biomedical approach was universalized. Originally developed in the global metropole (Connell, 2007), it was imposed throughout the world as the legitimate way of approaching the treatment of disease, the management of illness and the education of doctors. The assumption that biomedicine is objective and universal was bound up in the colonial projects whereby populations were exploited by clinical researchers in the name of science (Anderson, 2014; Good et al., 2008).
The biomedical model, which has dominated formal medical care in the global North since the end of the eighteenth century, is neatly summed up by Paul Atkinson (1988: 180) in the following way:
It is reductionist in form, seeking explanations of dysfunction in invariant biological structures and processes; it privileges such explanations at the expense of social, cultural and biographical explanations. In its clinical mode, this dominant model of medical reasoning implies: that diseases exist as distinct entities; that those entities are revealed through the inspection of ‘signs’ and ‘symptoms’; that the individual patient is a more or less passive site of disease manifestation; that diseases are to be understood as categorical departures or deviations from ‘normality’.
Students of sociology will no doubt quickly recognize the limitations of this approach to health, disease, illness and healing. The body is isolated from the person, the social and material causes of disease are neglected, and the subjective interpretations and meanings of health and illness are deemed irrelevant.
A further assumption inherent in Western medicine is that it is based on an objective science, which in turn involves empirical observation and induction. Medicine thereby claims to offer the only valid approach to the understanding of disease and illness. Secure in its approach, medicine has scribed its own history (Rhodes, 1985; BMA, 1992), such that its development is presumed to be one that has resulted in an increasingly accurate knowledge of disease. With this knowledge, it claims to have achieved a whole series of successes: it has eradicated certain diseases; it has eliminated erroneous ideas and practices; and it holds the promise for further advancements for the control of existing and any new diseases. Thus, medicine’s own history is one of progress. The development of medicine is presumed to involve a move from speculation to a coherent scientific discipline. This is typified by Philip Rhodes (1985: 3):
The general course of the history of medicine is from massive speculation – without allowing it to be much influenced by fact, as observed or derived from experiment – to narrower and narrower smaller hypotheses, potentially testable by observation and experiment. There is a move too from supernatural to natural explanations of phenomena; and it all takes a very long time, with the old clinging to the new, impeding its progress and having to be discarded as time passes, so that novel and fruitful ways of looking at events may emerge and be tested. In short medicine is one aspect of the development of scientific method being applied in one of the most diffcult areas of nature.
This type of account is a so-called Whig history: that is, one that sets out the achievements of the past and details how they have contributed to present success in a linear and progressive manner. Today such Whig accounts of, and approaches to, medicine are, for many, no longer acceptable (Jackson, 2011; Anderson, 2014). The sociology of health and illness has sought to offer alternative ways of interpreting medicine, health and healing. Much of this understanding has come about through criticisms of the biomedical model, some of which are considered below.

Challenges to Biomedicine

During the decades leading up to the start of the new millennium, the institution of medicine and the biomedical model were challenged by critiques emerging from both popular and academic sources. These criticisms have been intensified within the context of the escalating costs of health care. Medicine is not a homogeneous institution, and criticisms of the biomedical model and medical practice are voiced within medicine as well as outside it. Striking at the heart of biomedicine is the challenge to its effectiveness. It has been argued, from within both medicine (Engel, 1981) and sociology, that medicine’s efficacy has been overplayed. Thomas McKeown (1976), a professor of social medicine, for example, demonstrated by way of historical demographic studies that the decline in mortality that has occurred within Western societies has had more to do with nutrition, hygiene and patterns of reproduction (essentially social phenomena) than it has to do with vaccinations, treatments or other modes of medical interventions (see Chapter 9). Drawing on this type of evidence, authors have pointed to the fact that pouring resources into medical technologies has resulted in diminishing returns (Powles, 1973). Taking this further, Ivan Illich (1976) has argued that biomedicine does more harm than good. Rather than curing and healing, medicine actually contributes to illness through the iatrogenic effects of its interventions, such as the side-effects of drugs and the sometimes negative clinical consequences of surgery. This is evident in the history of mental health services, where pharmacological and surgical interventions, as well as other treatments such as lobotomies and electro convulsive therapy (ECT), which to our eyes might seem barbaric, were presented as innovative and progressive during the 1950s through to the late 1980s. Joanna Moncrieff is one of a number of critical psychiatrists who detail the political expediency of the adoption of drugs that have, or are presented as having, specific solutions to common illnesses such as depression. Writing on the history of the ‘antidepressant’, ...