The sociology of health and illness

Medical sociologists are one of the largest groups of sociologists in the world. They are found within sociology (sociology
department, middle schools, nursing schools, schools of public health), as well as outside academia and government agencies and
research organizations.

Weeks (2008): points to four important changes in medicine in the 1950s and 1960s that contribute to the rapid development of
medical sociology.

1. as generative diseases such as heart disease replaced infectious diseases as the primary cause of death, the role of social
patterns and lifestyles became more obvious.
2. Preventive medicine and Public health efforts drew attention to significant factors such as poverty and malnutrition
3. modern psychiatry emphasizes the role of the social environment in psychological healing.
4. Medicine became more bureaucratic and administrative, in the regulation and delivery of medical care.

Research funds were made widely available to study the social causes and consequences of health and illness.

Patterns of health and illness

They have changed considerably over time, along a specific trajectory labelled the epidemiological transition: historical changes and
patterns on morbidity and mortality from a predominance of infections and parasitic diseases to degenerative diseases.

Until very recently in human history, morbidity (the prevalence and patterns of diseases in a population) and mortality (the incidence
and patterns of death in a population) were concentrated in the young and were primarily the result of infectious and parasitic
diseases.

Later half of the 20th century: in the developed world, that morbidity and mortality became concentrated in the old population and
primarily due to degenerative diseases.

Historical patterns

Four phases in epidemiological transition

1. Characterized by famine, as well as infectious and parasitic diseases. In the Middle Ages, infectious diseases were rampant
and a series of epidemics swept through Europe. Example: the Black death.
2. Featured a decline in epidemics owing to improvements in agriculture and nutrition (people better able to resist diseases),
away from cities, and lower birth rates (improving women’s health). In the early 1800s, life expectancy increased to around
40 years. Although epidemics have declined, infectious diseases remain the primary cause of death, their transmission
facilitated by industrialization and urbanization. Infectious diseases remain the leading cause of death into the early 20th
century. Example: smallpox, measles, whooping cough.
3. Infections and parasitic diseases declined even further, and degenerative diseases (heart diseases, diabetes) became the
primary cause of morbidity and mortality. Improvements in agriculture and nutrition, development and Public health, and
medical interventions were responsible for decline in infections and parasitic diseases.
4. In the late 20th and early 21st century the fourth stage has emerged, during which an increase in degenerative diseases has
been accompanied by the emergence of view infectious diseases such as Ebola, HIV AIDS, and severe acute respiratory
syndrome. The overuse of antibiotics in medicine and livestock produced has created strains of drug-resistant bacteria that
medical science is unable to treat. In many parts of the world, urban development has disturbed ecosystems, bringing
unknown bacteria and viruses to the surface. Rapid population growth in many places has created crowded living conditions
that facilitate the swift transmission of infections. The transmission of new infectious diseases is also facilitated by global
travel.

Contemporary patterns of mortality in Canada

For both men and women, the two leading causes of death are cancer and heart disease. The third leading cause of death for
women in stroke, but for men it is accidents. Men are three times as likely to die as a result of suicide and twice as likely to die due
to liver diseases.
Two of the three leading causes of death among 1 to 44-year-olds (accidents and suicides) are, to a large extent preventable. But so
are the degenerative causes among the old and older age groups. The leading causes of death are listed in official records using
standardized terms from World Health Organization’s international classification of diseases, such as malignant neoplasms (cancer).

What are the actual causes of death? What causes stroke, respiratory diseases, or heart diseases?

Research into this question has found that the top three actual causes of death are tobacco use, alcohol misuse, and a poor diet
combined with physical inactivity. Sociological perspective shows us that those behaviours that many initially appeared to be a
matter of individual choice is are actually embedded in and affected by broader sociocultural forces. For instance, in Canada of the
regions that have the lowest life expectancy also have the highest rates of smoking, heavy drinking, and obesity.

The actual causes of illnesses: the role of lifestyle

Tobacco use is the leading cause of preventable death in the world, killing half of its users resulting in more than 6 million deaths per
year. Tobacco use is increasing globally, primarily due to smoking patterns in low and middle income countries, where 80% of the
world’s smokers live. Tobacco use has been declining in upper middle and high income countries, due to education and changing
governmental regulations, and varies on the basis of gender and age. Example: across all age groups, more mails (23%) than females
(18%) smoke.

The best predictor of future smoking patterns in society is the current smoking patterns of youth because most people who smoke
begin as teenagers, if someone hasn’t smoked by the age of 20 it is unlikely that he or she ever will.

A number of macrolevel factors contribute to smoking: cultural norms, the availability of tobacco products, tobacco control policies
and strategies, and the promotion of cigarettes by tobacco companies.

Advertising and marketing have the greatest impact on youth, around one third of smoking initiation in youth is a result of
advertising. Research suggests that images of smoking in movies have an even greater impact on youth.

Our attention was first drawn to the social contexts of health and illness by variations in the leading causes of mortality, based on
gender and age. Now we have seen that gender and age are also important in patterns of tobacco use and that the movie industry is
a powerful force in the initiation of youth smoking. The social contexts of lifestyle factors associated with health and illness are also
important for understanding patterns of alcohol use and misuse.

Alcohol use and misuse

It is directly related to more than 3.3 million deaths worldwide per year, but the harms caused by alcohol misuse vary across nations.
Those countries with High level of alcohol use, combined with poor public health resources, experience more morbidity and
mortality.

There are significant variations in alcohol use based on both gender and age: men are more likely than women to drink, and male
and female drinking patterns vary as well. Men drink more frequently and more likely to engage in heavy or binge drinking.

There are also a variations in alcohol use: adults over 25 are more likely to consume alcohol then or 15 to 24-year-olds. Youth are
more likely than adults to engage in high-risk drinking (number of drinks consumed in a single session and in a one-week period of
time).

Despite the role that alcohol misuse plays in morbidity and mortality on a global level, WHO finds that governments are less willing
to develop reduction strategies for alcohol then for tobacco use. Governments derive economic benefits from tobacco and alcohol
sales and production. Also, alcohol holds a central place in the economies of many countries, and has for centuries.

Liters of absolute alcohol: calculation that standardizes the amount of pure alcohol sold (accounting for differences in the overall
content of beer, wine, and sprites); this enables one liter of any type of alcohol to be equated with one liter of any other type of
alcohol. In Canada, 233 million L of absolute alcohol were sold. Governments, when they craft policies for alcohol, tried to strike a
balance between long-term health and shorter term economic development.
Poor diet and physical inactivity

What you eat and how much physical activity you engage in has a significant impact on health and illness. Several factors play a role
in morbidity and mortality: poor habits, a lack of physical activity, and being overweight or obese (low consumption of fruits and
vegetables associated with 1.7 million deaths per year and physical inactivity accounts for 3.2 million deaths).

Overweight and obesity are not just characteristics of high income countries anymore, they are also found in middle and low income
countries, which often face a double burden of high obesity rates and concurrent high malnutrition rates.

CANADA

Eating Habits

2004 Canadian community health survey: half of adults were not eating enough fruits and vegetables, nor were 60 to 70% of
children between four and 13. A significant proportion of Canadians were not consuming sufficient amounts of dairy, grains, or
proteins either. One for group that all Canadians were consuming more than enough of was the “other”: soft drinks, salad dressings,
sugar/syrups/preservers, beer, and fats. They are low in nutrients, high calorie foods comprise approximately one quarter of all
calories consumed.

Physical inactivity

health Canada by the following guidelines for physical activity: adults should engage in 150 minutes of moderate to vigorous physical
activity weekly, and children, 60 minutes daily.

Only 50% of adults engage in recommended levels of activity, men are more physically active than women, and the most active age
group is 18 to 39-year-olds.

Even smaller proportion of children meet the recommendations. Most active group is boys aged 6 to 11 (11% engage in the
recommended level of activity), the least active girls aged 12 to 17 (2% engage in recommended levels of activity).

Children’s physical inactivity is of particular concern because of the short and long-term health implications. One response has been
the establishment of the quality daily physical education program: a set of guidelines for high quality physical education in schools.
Standards include a minimum of 30 minutes of varied physical activity daily, qualified teachers, and an emphasis on fun. It is clear
that once again sociocultural forces are playing a role in children’s patterns of physical activity and inactivity, with the negative
health outcomes, such as weight problems.

Overweight and obese

a poor diet and physical activity are associated with weight problems, although these behaviours have a negative impact on the
health of people without weight problems as well. One way that adult weights are classified is with the body mass index, because it
can be applied accurately to most adults, WHO considers it a useful measure of risk at the population level, where the risk of chronic
diseases increases progressively with a BMI over 21.

At the individual level, the BMI should not be applied to certain people. Example: bodybuilders and people of Inuit dissent have
atypically high levels of muscle mass relative to height, for them a high BMI is not necessarily indicative of being overweight.
Research has also found that for elderly people, a high BMI is not an indicator of health risks, but rather is associated with lower
mortality rates.

BMI of 25 or higher = overweight, 30 or higher = obese.

Behaviours related to smoking, drinking, diet, and physical activity are significant for national and global patterns of morbidity and
mortality. Initially, these choices appear as microlevel behaviours. However if lifestyles were purely a matter of individual choice,
then related behaviours would be randomly distributed across social groups and we would not see the gender and age pattern
mentioned earlier. These patterns tell us that something more than lifestyle is at play. When we shift our focus to an even more
macrolevel, we find fundamental causes of health and illness, and we learn that their foundations are rooted in social equality.

The fundamental causes of health and illness: social equality

sociocultural forces are intertwined with stratification in the society and in this regard, two of the most significant fundamental
causes of health and illness are social economic status and ethnicity.

Socioeconomic status

single most important determinant of health globally is socioeconomic status: a higher position in the social structure is associated
with better health. Example: Canadians who live in less affluent neighbourhoods have a greater risk of heart attack, more likely to
die following the cancer diagnosis.

Comparing people who are in the lowest and highest socioeconomic quintiles, we find numerous health differences. Example:
Canada: women in the highest quintile live an average of 2.3 years longer than those in the lowest quintile, while men in the highest
quintile live for 4.7 years longer than those in the lowest one.

Heart disease: low socioeconomic status during childhood has the greatest impact, independent of socioeconomic status in
adulthood.

Socioeconomic status is associated with access to material resources, such as adequate housing, safe neighbourhoods, healthy food,
clean water, clean air, educational opportunities, and control over one’s work. A lack of material resources can have a direct impact
on health and illness. It can also indirectly affect health and illness through factors such as chronic stress.

Stress: causes physiological changes in the body, such as an increase in heart rate and blood pressure and the release of hormone
cortisol. These changes can be functional when we are facing an immediate threat (being chased by a bear) or a short-term stressor
(having to stay awake to complete a term paper). Stress in the long term (ongoing job insecurity), the physiological changes are
dysfunctional and contribute to high blood pressure, heart disease, and digestive diseases.

Control of destiny: important contributor to health and illness, people of lower socioeconomic status have a feeling of less control
over their lives, and this may reduce the impetus to engage in healthier behaviour. Smoking can give the false impression of easing
stress, and the effects of alcohol can provide a temporary escape.

Physical activity can be a challenge: low socioeconomic status means that people cannot afford gym memberships. Can’t run
outside = dangerous neighbourhood or environmental conditions. It can also mean that working more than one job, leaving little
leisure time for physical activity.

Eating an adequately nutritious diet: is also more challenging for low income individuals. Processed, high calorie, low nutrition food
are often much cheaper than healthier foods. Example: nutritious diet costs $1.5 more per meal. People may have limited access to
healthy foods: having access to supermarkets is associated with better eating habits (they provide a wide range of nutritious foods,
at lower prices). People living in low income neighbourhoods are less likely to have access to a supermarket.

Because of the higher costs of a healthy diet and the difficulty some social groups have accessing healthy foods, food insecurity is an
issue for many Canadians (statistics Canada: more than 1 million household experience food insecurity).

Socioeconomic status had an impact on the extent to which people engage in lifestyle behaviours related to tobacco, alcohol,
physical activity, and died. Even when lifestyle factors are controlled for socioeconomic status continues to have an impact on
morbidity and mortality. Socioeconomic status also impacts mental health.

Socioeconomic status and mental health

Mental illness is both a contributor to and an outcome of lower socioeconomic status. The social selection hypothesis : proposes that
if people’s mental disorders are not effectively treated, they may experience functional difficulties in school or work that caused
them to drift into a lower socioeconomic status or prevent them from rising into a higher status position. Social causation
hypothesis: a lack of material resources creates stress, which contributes to the development of mental disorders. Research leads to
greater support for this hypothesis especially for depression and anxiety.

Besides social economic status, several other social factors are associated with poor mental health. These include rapid social
change, low levels of education, stressful work conditions, gender discrimination, and human rights violations.
Ethnic inequality and health

Ethnicity and socioeconomic status are the two primary functional causes of health and illness. The relationship between ethnic
inequality and health Is especially evident in health patterns for aboriginal populations and for the recent immigrants to Canada.

Aboriginal health: the legacy of colonialization

indigenous populations face higher morbidity and mortality then non-indigenous populations. In Canada, aboriginal populations are
more likely to experience degenerative diseases such as diabetes, cancer, heart problems. Also more likely to die from accidents, life
expectancy is five years less for men and seven years less for women.

Variations in morbidity and mortality among aboriginal groups, based on specific aboriginal identity (first Nations, Inuit, or Métis), on
or off reserve, and rural/remote versus more urban place of residence.

Most important factor affecting aboriginal health are related to socioeconomic status: income inequality, low-quality employment,
and the lower levels of education.

Colonization has had a great impact on aboriginal people’s socioeconomic status, and health. In these populations, control of destiny
is affected not only by lower levels of social economic status but also by a long history of laws and federal policies that have imposed
control over their treaty status, marriage and divorce, education, place of residence, medical treatment, housing, and more.

The transition from traditional diets has had a significant impact on health, especially in terms of heart diseases and diabetes. This
reflects the trend towards packaged and processed foods across the developed world. Also as a result of resource extraction and
hydroelectric development, environmental toxins have made their way into the fatty tissues of Fish and game, making them unsafe
for consumption. Result: some communities have had to abandon their traditional hunting and fishing activities.

These communities also face greater food insecurity because of their lower economic status and remote locations.

Immigration and health

socioeconomic status alone does not explain patterns of morbidity and mortality by ethnicity. Recent immigrants are actually
healthier than people who are Canadian born, this is known as healthy immigration affect. Immigration policy prioritizes those who
have higher levels of occupational skill and education, which means that immigrants tend to be located at higher levels of social
structure in their countries of origin and therefore experience the health benefits of their old social positions.

This affect quickly disappears, especially for women and racialized groups. In 4 years, their health patterns become similar to those
of people who are Canadian born. Despite the higher statuses they may have occupied in their countries of origin, as well as their
higher level of education, people who are foreign-born have lower occupational status and lower incomes then people were native
born.

Even when controlling for socioeconomic status: declines in health status persist. Difficulty with English or French language
proficiency, higher levels of discrimination, social isolation, and higher levels of stress are associated with poor health.

Summary: across social groups, socioeconomic status is the primary fundamental cause of health and illness, for it affects access to
material resources such as adequate housing, safe neighbourhoods, healthy food, clean water, and air, educational opportunities,
and control over one’s work. Socioeconomic status also have an impact on lifestyle behaviours and control of destiny. As a result,
people of lower social economic status are of poorer health, have higher mortality rates, and have lower life expectancy than people
in higher social economic status. Ethnic inequality is another important fundamental cause of health and illness. Although it interacts
with socioeconomic inequality, there are dimensions of ethnic inequality level beyond social economic status.

Healthcare systems

The prevention and treatment of illnesses and injury exists in the broader context of healthcare systems. In Canada the first systems
of medical care were those of aboriginal cultures, each of which had its own definition of what constituted health and illness, as well
as its own medical treatment. Medical care was provided by shamans, medicine men, or other members of the community.

Early settlers in new France: received medical treatment at the hands of apothecaries who acted as general practitioners, and barber
surgeons. Euro Canadians received treatment from a wide variety of practitioners: midwives, homeopaths, and for the wealthy
physicians trained in the United States or Great Britain.
1832: Canada’s first medical school was established, after the implementation of the medical act (1869), a number of privately
owned medical schools opened and would later become affiliated with various universities. 1912: Canada medical act, that licensing
procedures and criteria were standardized in Canada.

1957: with the hospital insurance and diagnosis service act, the first publicly funded medical institution open. This act provided for
medically necessary care and services in hospital settings.

1968: medical care act, which created Canada’s system of universal medical insurance, more commonly known as Medicare. Four
objectives: universality, equal access to medical care for all residents of Canada regardless of income, age, social, or previous health
conditions. Portability, across provinces. Comprehensive coverage, of all necessary medical services and administration that would
be nonprofit. 1989: a fifth objective was added, accessibility: Medicare would involve the redistribution of income from richer to
poorer provinces.

Health care system today

Because of Medicare, Canadians have more access to medical services than in the past. Canada has lower physician to population
ratio than most other member countries of the OECD. 2011:2.4 physicians per 1000 population.

The shortage of family and general practitioners in particular has resulted in widespread concern over the Dr. shortage, more and
more Canadians have to use walk in medical clinics, where wait times are long and staff turnover is high.

Some medical services require out-of-pocket expenses (dental care, prescription medication), which not all Canadians can afford.

Health care system today: state of transition, at a time when concerns are growing about out-of-pocket medical expenditures, a
shortage of physicians, and long wait times in the nations emergency rooms, governments are expressing concerns about the rapidly
rising costs of healthcare.

Part of efforts to strike a balance between the demand for care and other competing priorities while at the same time controlling
costs, alternative models are being explored including changes in the federal contributions to health care and the possibility of
parallel private healthcare systems.

The rising cost of healthcare

2011: OECD nations that spent the most per person on health care was a United States at $8508. Canada was in the top 20% of
nations in per capita healthcare spending (4522) in the same bracket as other nations with publicly funded healthcare systems
(Netherlands, Austria, Germany, Norway).

The aging population: as more people in a population come from older age groups, healthcare utilization increases. Medical age: the
age that divides the population in half, in 1956 was 27.2 years, by 2012 it was 40 years. You can see that age by sex structure of the
population by looking at the population pyramid, a horizontal bar chart that shows how many people in a population are members
of particular age groups, divided by sex.

Implications of the aging population: as people age, more likely to develop chronic health conditions. Two most common are high
blood pressure (47% of seniors have) and arthritis (27% of seniors have). It is not age itself that determines healthcare utilization, but
it is the presence of multiple chronic conditions. Seniors with three or more chronic health conditions made three times more visits
to health professionals than those with only one or two conditions.

Chronic conditions are not inevitable but they are closely linked to lifestyle behaviours, which are intertwined with social factors
such as social economic status.

Ramage-Morin and shields (2010): analysed eight different lifestyle behaviours among people aged 45 to 64, and 65 and over,
related to smoking, BMI, physical activity, diet, sleep, oral health, stress, and social participation. Each of these behaviours was
individually associated with health, the greater the number of positive behaviours the better the resulting health.
Sociology and theory

functionalist perspective: the sick role

Talcott Parsons: one of the preeminent sociologists of the mid-20th century. Theorized about the sick role, he added legitimacy to
the new field of medical sociology. He described sickness as dysfunctional for society. When people are sick they are unable to fulfil
their role as students, employees, or parents. Instead they adopt the sick role, a temporary role associated with certain rights and
response ability.

Four components of the sick role: (a) the sick person is granted a temporary exemption from his or her normal social duties.
Acceptable to miss an exam or a day of work, although some official documentation as may be required to legitimize the absence.
(B) the sick person is not considered to be responsible for his or her condition, but rather given sympathy. (C) it is the sick person’s
responsibility to try and get well, failure to do so results in sick role no longer being considered legitimate. (D) it is the sick person’s
responsibility seek competent technical help and cooperate with the physicians directions.

The components of the sick role do not always apply. Example: the extent to which someone is exempted from normal social roles
varies with the nature and severity of the illness (a cold may not be considered a legitimate excuse for missing a day of work).

De Maio (2010): finds that sometimes individuals are blamed for the illnesses. Example Perry (2011): found that people who are
diagnosed with more severe mental disorders have larger, more functional support networks than those diagnosed with mild or
mental disorders. Because the symptoms of the latter are less overt, other people may wonder why the individual doesn’t simply
snap out of it, they are assigned responsibility for their own lack of well-being. Finally, even when able to legitimately occupy a sick
role, some individuals face constraints. Those of lower social economic status may not be able to afford to lose the wages associated
with missing one or more days of work.

Interactionist perspective: the cultural meaning of health and illness

Focuses on the experience and meaning of health or illness. Schnieider and Conrad (1983): distinguished between sickness and
illness. Sickness is pathology of the body, while illness is the meaning attached to that physical experience. They found that
something as seemingly straightforward as following physician’s instructions is actually embedded in a complex system of meaning
and understanding, this is the individual’s experience of illness. Using medication is not simply a matter of following physician’s
instructions, it emerges from the interaction between physician’s instructions and one’s own relationship, beliefs, and experiences.
For example: the manner in which people with epilepsy use their medication is based on factors such as the meaning that the
seizures have for the individual, perceptions of the side effects of the medication, the desire to prevent others from becoming aware
of the epilepsy, and the need to prevent seizures in some social situations more than others.

Sense of self lies at the core of peoples experiences with illnesses. Example: people have been diagnosed with cancer reveal a loss of
personal control, changes in self-esteem and self-worth, and changes in body image.

Conflict perspectives: the consequences of power and inequality

The interactionist perspective emphasizes the subjective meanings of health and illness at the micro level, conflict theory focuses on
the macro level. Analyse topics such as the role of inequality in patterns of health and illness, and the problems with healthcare
systems. Because of social inequality and relations of power, different groups have varying levels of access to both health promoting
resources and sickness causing factors.

Engles: first conflict theorist to address social economic influences on health and illness. Argues that with capitalism, large number of
people left rural agricultural life for wage labour in urban areas. But the bourgeois owners of the means of production were guided
by their own profit motives. To make the largest profit possible, they underpaid their workers, who had no choice but to live and
work in an unhealthy condition. This set the stage for the emergence and transmission of infectious diseases.

Navarro (1979): indicates that there is an inherent contradiction between the profit motives of capitalism and the health needs of
people. The corporate need for profit that result in people having to live or work in unhealthy conditions has continued beyond
Engles time, in the 21st century, during which multinational corporations are moving their production facilities to low income
countries that often have lower occupational health and safety standards.

The theory also critiques the health care system itself: the state’s power to legitimize some forms of healthcare (visit to a physician)
over others (visit to a holistic health practitioner), and the power of the corporate elite in the health care system. Capitalist system,
health becomes a commodity and the pursuit of health occurs via gym memberships, athletic shoes, vitamins and supplements.
Health is about convincing people to engage in health promoting behaviour, rather than about changing the structural conditions
that contribute to health and illness in the first place.

Feminist perspective: women’s health and illness

Feminist analysis of health and illness are diverse and addressed topics ranging from the micro level to the macro level. Example: at
the micro level Werner and Malterud (2003): analyse the credibility work that women with chronic pain engage in when trying to
manage their interactions in the healthcare system. They suggest that this tendency to dismiss women’s physical symptoms as the
result of stress or anxiety rather than physical illness, has continued to this day.

At a more macro level, some feminist analysis of health and illness have focused attention on the process by which certain
characteristics and conditions come to be perceived as indicative of health or illness in the first place. They have analysed the
medicalization of women’s lives, which refers to the ways that certain characteristics and conditions are defined in medical language,
understood through the adoption of a medical framework, or treated with medical intervention. Example: most of human history,
issues related to pregnancy and childbirth were handled by other women, such as midwives. But in the more medicalized
environment of the 20th century, both became conditions that require physician’s care.

Postmodern perspectives: knowledge, power, and discourse

Also addresses the medicalization of society, in terms of the relationship between knowledge and power. Those claims to truths that
emerge from institutionalized positions of power become legitimized and accepted as truth. Example: As medical science becomes
increasingly intertwined with rational bureaucratic care systems in the 20th century, physicians claims about health and illness gained
supremacy over those of other types of health practitioners such as midwives.

Once medical discourses become increasingly legitimized, more aspects of people’s lives are subjected to the medical gays and
monitored by the medical profession. And because medical discourses are a elite discourses, we perceive them as the only possible
means of understanding the world.

Fox (1993): applies Foucauldian assumptions to an analysis of communication between physicians and patients during post surgical
ward rounds. Notes that the way that surgeons structure post operative communication ensures that a medical discourses remain
privileged. Physicians begin these communications while the patients are still recovering from sedation, which immediately limits the
extent to which patients can participate in the communication. The structure of postsurgical discourses involves a transition from
communicating about the patients physiology, to the condition of the wound, to aspects of recovery/discharge. When patients try to
disrupt this linear transition, physicians quickly use medical discourses to bring the communication back on track. As a result, the
nature of communication between doctor and patient at the micro level helps reinforce the power of medical discourses and society
at the macro level.