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Social Science & Medicine 73 (2011) 939e943

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Social Science & Medicine


journal homepage: www.elsevier.com/locate/socscimed

From diagnosis to social diagnosis


Phil Brown*, Mercedes Lyson, Tania Jenkins
Department of Sociology, Brown University, Box 1916, Providence, RI 02912-1916, United States

a r t i c l e i n f o a b s t r a c t

Article history: In the past two decades, research on the sociology of diagnosis has attained considerable influence
Available online 12 June 2011 within medical sociology. Analyzing the process and factors that contribute to making a diagnosis amidst
uncertainty and contestation, as well as the diagnostic encounter itself, are topics rich for sociological
Keywords: investigation. This paper provides a reformulation of the sociology of diagnosis by proposing the concept
Diagnosis of ‘social diagnosis’ which helps us recognize the interplay between larger social structures and indi-
Risk
vidual or community illness manifestations. By outlining a conceptual frame, exploring how social
Social movements
scientists, medical professionals and laypeople contribute to social diagnosis, and providing a case study
Environment
Public health
of how the North American Mohawk Akwesasne reservation dealt with rising obesity prevalence to
USA further illustrate the social diagnosis idea, we embark on developing a cohesive and updated framework
Canada for a sociology of diagnosis. This approach is useful not just for sociological research, but has direct
Reservations implications for the fields of medicine and public health. Approaching diagnosis from this integrated
perspective potentially provides a broader context for practitioners and researchers to understand extra-
medical factors, which in turn has consequences for patient care and health outcomes.
Ó 2011 Elsevier Ltd. All rights reserved.

Introduction how to apply our social diagnosis approach. Lastly, we conclude


with implications for sociology, medicine, and public health.
Sociological analysis of diagnosis has achieved considerable
influence in the last two decades, providing important insight into
how we understand health, disease, and illness. It has also Introducing social diagnosis
expanded how we view the social and cultural influences that
shape our knowledge and practice on health and illness. Social diagnosis is ‘social’ for two reasons: First, it connects an
This includes studies of diagnosis that have gone beyond the illness or the act of diagnosing that illness to a set of political,
interaction between physician and patient, to take into account the economic, cultural and social conditions or factors. Second, social
larger social, structural, and temporal forces that shape diagnosis diagnosis is conducted by different social actors, and the actions of
(see, for example, the categorization of homosexuality as a mental one group of stakeholders often spill over to affect the actions of
disorder and the role of gay rights activists in the American other actors. As we will see, social diagnosis is done by sociologists
Psychiatric Association’s deliberations) (Cooksey & Brown, 1998). who study diagnosis, as a way for researchers of social medicine and
Recently we have also seen the emergence of diseases whose the social determinants of health to look at the process, outcomes,
etiologies, symptoms, and, therefore, diagnoses, are often contested and consequences of diagnosis. It is also done by the lay public vis-
or uncertain. This combination of medical and social uncertainty à-vis social movements that expand what goes into the diagnosing
leads us to propose a reformulation of the concept social diagnosis as process. In this more comprehensive, public version of uncovering
a new way of thinking about the sociology of diagnosis. This paper the social determinants of health, a condition is diagnosed by
explores social diagnosis by first, outlining a conceptual framework a social groupdfor example, the politicized collective illness iden-
of social diagnosis; second, discussing the different actors who tity that arises over a contested disease like Gulf War Illness
contribute to social diagnoses; and third, providing a case study of (Zavestoski, Brown, Linder, McCormick, & Mayer, 2002). Lastly,
social diagnosis is a way to expand the lens of the public health and
medical establishment in identifying what mechanisms and factors
are consequential for individual and community health. Social
* Corresponding author. diagnosis therefore provides a broader context for health practi-
E-mail address: Phil_Brown@brown.edu (P. Brown). tioners, medical researchers, and social scientists to understand the

0277-9536/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2011.05.031
940 P. Brown et al. / Social Science & Medicine 73 (2011) 939e943

extent of extra-medical factors in health and illness. With that seeking improvements in neighborhood parks and fighting for lead
approach, neighborhood and community environments (which are removal and blood lead testing (Lefkowitz, 2007).
themselves determined by larger structural forces) can be included While the public health field in the US continued a strong
in approaches to wellness, highlighting the intersection between commitment to examining social factors in disease, medicine often
individuals and the larger social forces that structure their lives. trailed after it. Occupational health, environmental health, nutri-
tion, and community health training still remain marginalized in
A genealogy of social diagnosticians medical education and practice. Federal research, largely conducted
through the National Institute of Health, emphasizes treatment
Social scientists over prevention. For example, the prestigious, well-funded
National Cancer Institute provides few resources for researching
The roots of this approach are deep. The term “social diagnosis” environmental causation, leaving that to the much smaller National
was coined in Richmond’s (1917) book, Social Diagnosis, considered Institute of Environmental Health Sciences whose budget is 6.5
to be the classic textbook laying a professional foundation for social times smaller (Brown, 2007) Sociologists have played a role in
work, and which focused on examining a wide array of social examining social factors in disease, working alongside public
conditions causing poverty and disease. This was a period when health scholars and community activists in pursuing multi-causal
sociology and social work shared many common interests in doc- approaches to understanding disease and developing multi-
umenting and alleviating poverty, with the reformist Chicago pronged solutions (Brody et al., 2009).
School sociologists categorizing and analyzing urban social prob-
lems that they traced to social structures rather than inborn Public participation/social movements
characteristics.
Even in the early 20th century, sociology focused on the social Diagnosis is simultaneously a site of compromise and contes-
determinants of health and illness, as in Faris and Dunham’s (1939) tation because it is a relational process. When there is a disconnect
work on mental illness. Decades later, Navarro (1976) and Waitzkin between the patient and the medical explanatory model, the
(2000), both MD/PhD sociologists, led the charge of other political individual may be unsatisfied with treatment goals, and collectively
economy scholars who sought to rekindle social medicine, found as work to politicize the illness through social movements. This would
early as Rudolf Virchow’s work in mid-19th century Europe, and be the case especially if people were not given a diagnosis for
more recently in Chile during Allende’s Popular Unity Government something which they expected to, or when they received
in the early 1970s. a psychiatric diagnosis for something they believe is physical.
A committed approach to health inequalities, rooted in England, The greater the symptom severity or the disconnect between lay
worked its way into the literature starting in the 1990s. A leading and professional perspectives on diagnosis, the greater the likeli-
medical sociologist, Sol Levine, and a prominent social medicine hood of contestation.
physician, Alvin Tarlov, nurtured this endeavor in their Health and In contesting diseases and conditions, people often seek to
Society group, publicizing well-known British work such as Michael reshape or overturn a shared set of entrenched beliefs and practices
Marmot’s Whitehall Study, bringing key health inequalities about diagnosis, causation, and treatment that is embedded within
researchers such as Richard Wilkinson to the US as visiting scholars, a network of institutions, including medicine, law, science,
and providing a research setting to nurture new health inequalities government, health charities/voluntaries, and the media. This
researchers (Amick, Levine, Tarlov, & Walsh, 1995). A young gener- network is the “dominant epidemiological paradigm” for a given
ation of US-based scholars brought health inequalities work to the disease. Activists challenge the dominant epidemiological para-
fore, emphasizing race, class, sex, ethnic, and neighborhood differ- digm by shifting the modes of scientific inquiry, and by refocusing
ences (Kawachi, Kennedy, & Wilkinson, 1999; LaVeist, 2002; regulatory and policy attention (Brown, 2007). Scientists may be
Williams, 1994). These scholars’ work helped push the National asked to weigh in on questions that are virtually impossible to
Institutes of Health to develop a strong program in health inequal- answer scientifically, either because data do not exist or because
ities, though usually termed “health disparities,” a more neutral- studies required to answer the question at hand are not feasible.
sounding phrase. From being only a National Center on Minority Scientists may frame political, moral, or ethical questions in
Health and Health Disparities, in 2010, NIH transformed the center scientific terms thus limiting lay participation. This scientization
into a full institute, the National Institute on Minority Health and protects the illusion of medical omnipotence and delegitimizes
Health Disparities, signifying a major acceptance of this work. questions that cannot be framed in scientific terms (Morello-Frosch
et al., 2006). Health social movements may respond to these situ-
Public health and medical professionals ations by marshaling resources to conduct their own research and
produce scientific knowledge in a process known as “popular
Medical professionals and public health scholars in the US share epidemiology” (Brown, 2007). In doing so, they democratize the
an important tradition of taking into account social factors in their production of scientific knowledge and then use that transformed
work. For an example of 1960s social medicine that exemplifies science as the basis for demands for improved research on disease
social diagnosis performed by a physician, we can remember the etiology, treatment, prevention, and stricter regulation.
work of Dr. Jack Geiger, a founding member of the Congress of Racial These concerns may extend into the legal realm when diagnoses
Equality (CORE) in 1943, a leader in efforts to end racial discrimi- are a classification of what the individual’s health status could be in
nation in hospital care and medical schools admission and a 1960s the future. Exposed people may seek redress through medical
founding member and National Program Chairman of the Medical monitoring torts in advance of injury, in an attempt to offset the
Committee for Human Rights which protected and provided medical costs associated with periodic testing in order to ascertain whether
care for civil rights workers. Geiger was famous for diagnosing a given exposure has led to changes in health status (Maskin,
poverty, racism, and hunger, and writing prescriptions for food to Cailteux, & McLaren, 2001). Even US law now recognizes that
give to poor children, which he and colleagues did to garner public disease is no longer a unique collection of symptoms equaling
attention. More practically, the community health centers devel- a given condition, but rather a constellation of current symptoms,
oped in that era diagnosed disease as stemming from a multitude of previous exposures, and future potential manifestations, all of
social conditions. For example, staff would act on these diagnoses by which make the art of diagnosis even more precarious.
P. Brown et al. / Social Science & Medicine 73 (2011) 939e943 941

The democratization of medicine and science we have population exposure measurement and to the diagnosis of
mentioned above is made possible by bringing the discussion of pre-disease. Combined with increased academic and advocacy
diagnosis out into the open, rather than keeping it restricted to research in this area, biomonitoring and household exposure
professionals. Krimsky (2002) notes that the endocrine disrupter has opened vast new realms of seeing potential disease causes
hypothesis (that argues for the central role of endocrine-disrupting at microscopic levels. Therefore, in a social diagnosis frame-
chemicals in many diseases) was discussed quite extensively in the work, not only are social factors considered in the diagnosis,
public light, far beyond the shelter of academic journals and but a variety of social actors are contributing to the creation of
government funding agencies. His notion of a “public hypothesis” that diagnosis. In doing so, they diagnose not only individuals
helps us see that increasingly, challenges to scientific orthodoxy are but societiesda practice which is growing ever more important
shaped by public discussion in the media, social movement orga- in light of increasing biomedical uncertainty.
nizations, virtual communities, and other accessible formats
(e.g. homosexuality, post-traumatic stress disorder). When people To further elaborate on and exemplify this idea of social diag-
view their diagnosis as stemming from a particular toxic exposure, nosis, we will use the case of obesity and diabetes in Akwesasne,
they are rarely satisfied with the simple act of diagnosis. Rather, a Mohawk reservation straddling New York and Canada. This situ-
they seek evidence of causation in order to seek redress in various ation demonstrates how diagnosis has moved from the individual
forms: medical coverage, medical monitoring, relocation, to society, and is being performed by more than just doctors.
compensation, assignment of blame, and (less commonly) the
incalculable but valuable apology from responsible parties. The multiple layers of diagnosis in obesity and diabetes: A
As discussed earlier, in the absence of a specific diagnosis, people case study of social diagnosis in action
with a shared environmental exposure sometimes file suits for
medical monitoring, to ensure that they have lifetime checkups to Obesity and diabetes have become a major concern of both
diagnose a disease process as early as possible. environmental justice and health groups in the 2000s. There is
Yet despite a rich history of social diagnosis exercised by various broad understanding that, in addition to individual and lifestyle
actors, including sociologists, public health officials and the public, factors, obesity is caused by numerous social phenomena:
the above-mentioned strands have not yet been well-connected, increased consumption of processed foods (especially high fructose
nor woven into a social diagnosis framework. Below, we discuss corn syrup), food deserts, poor school lunch programs, a decline in
several elements of a social diagnosis model. school physical education, and unsafe recreation spaces. Social
diagnosis looks here at an unhealthy body within an unhealthy
1) A social diagnosis approach is more comprehensive than community, itself situated in an unhealthy food system.
a political economy/health inequalities outlook that accounts Hoover’s (2010) medical anthropological study of local food
for how larger social structures affect diagnostic processes. In production and community illness narratives in the Akwesasne
social diagnosis, we also must “socially diagnose” those struc- Mohawk community found diabetes to be a central concern. Rising
tures themselves. In this light, we would argue that the injured prevalence indicated a rate higher than both the state and national
foot of a ballet dancer is not merely an injury caused by a pointe averages, and lay awareness of this led to a complex set of diag-
shoe. It includes the larger setting of the balletic art form e its noses. Residents in this highly contaminated area (primarily due to
teachers, theaters, dance companies, dance critics e as socially PCBs and fluoride from local industry) believed that there were two
iatrogenic. It includes gender roles that force-fit women into potential pathways through which contamination increased
many uncomfortable clothes and shoes, and anorexogenic diabetes risk. The direct pathway was based on recent science
notions of beauty that limit the art form. Our diagnosis would linking exposure to endocrine-disrupting chemicals, to obesity
be of an unhealthy foot in an unhealthy art form in an (Baillie-Hamilton, 2002; Newbold, Padilla-Banks, Snyder, Phillips,
unhealthy culture. Treatment and prevention goes beyond the & Jefferson, 2007). The indirect pathway was based on fear of
individual, seeking to restructure power, capacity, and contamination, including fish advisories and concerns over soil
community in the surrounding society. contamination, leading people to abandon traditional local foods
2) Traditionally, diagnosis dealt with diseases and symptoms in for less healthy processed foods, and hence also getting less exer-
the past and present, with future orientation toward only cise since they were not gardening and fishing. This second
treatment and prognosis. Indeed, even attempts at incorpo- pathway, rooted in a risk society perception, also led to changes in
rating social factors into diagnosis (either by healthcare the traditions and cultures of the community, leading to a broader
professionals or sociologists) do not adequately account for social illness.
a third dimension of time; that is, the future. Today, potentiality We do not imply here that the discovery of contamination led to
is an important concept, where a biomarker may or may not obesity. Rather, the discovery of the toxicants set off a cascade of
indicate future diseases. This potentiality introduces new events that meshed with other reservation developments, which
contestations and foci; preventive medicine now goes beyond then involved dietary and agricultural changes. Such changes have
generic health advice, to consider borderline categories: occurred in other communities, sometimes because of contami-
pre-diabetes, pre-high cholesterol, pre-hypertension. Further, nation discovery and sometimes for different reasons such as urban
patients are increasingly prescribed pharmaceuticals to regu- decline. This then leads to the departure of groceries with fresh
late these borderline conditions (Welch, Schwartz, & Woloshin, produce or to the immigration of people from more self-sufficient
2011). Therefore, a social diagnosis approach must contend not food regimes to urban locales flooded with fast-food restaurants
only with past and present conditions, but explicitly consider and completely lacking any resources to continue traditional
the potentiality of future conditions, specifically because they practices.
may have social causes and consequences. Using Chaufan’s (2004, 2008) work, Hoover argues that
3) The process of diagnosis is carried out by multiple social actors, the medicalized approach to diabetes individualizes and depoliticizes
including medical professionals, researchers, government the problem. Alternatively, a political ecology framework emphasizes
agencies, private corporations, social movements, and legal social, economic, and political institutions of human environments
institutions. For example, we can understand the role of public where diabetes is emerging. Hoover adapts Scheper-Hughes and
health agencies in new forms of surveillance geared to Lock’s (1987) model of three bodies e the individual body, the
942 P. Brown et al. / Social Science & Medicine 73 (2011) 939e943

social body and the body politic. As Hoover points out, in addition to 2) Social diagnosis recognizes commonalities in the group
losing the nutrition from fishing and gardening, people also lost the experience;
physical and cultural activity involved in that food production. This 3) Social diagnosis moves beyond a diagnosis that is limited to
led to fewer burned calories, affecting the individual body, but also to treating or identifying symptoms and toward identifying more
broader losses affecting the social body e the failure to connect with macro-structural roots. From here, it prescribes identifying and
ancestral ways and to pass traditions onto youth. Eating is an treating the fundamental causes of the problem, as opposed to
important social experience, and the sharing of food is an integral just the proximal symptoms;
part of Mohawk culture, full of morals around cooperation and 4) Social diagnosis relies on scientific evidence, but recognizes
proper behavior. This larger unity of the body politic is especially that useful science might not always come from mainstream
important at present, when the community is less united due to sources, particularly when it involves laypeople;
overlapping tribal, US, and Canadian governing bodies. Akwesasne 5) Lastly, social diagnosis is attentive to changes across both the
environmental health activists used their mobilization around short and long term. It moves beyond a cross-sectional approach
contamination as a way to achieve general social unification and to diagnosis and instead preferences a multi-temporal approach
harmony. When people seek to take control of individual and social to diagnosis, one that changes over time.
levels of obesogenic and diabetogenic conditions, this crisis that
originates in massive contamination has the capacity to provide new Social diagnosis offers three benefits: it is a concept that can be
unity. used by diverse actors – medical sociology and other medical social
In effect, we see that what might appear as a straightforward sciences, public health, and medicine; it is not only about diag-
diagnosis of a metabolic disease is in fact much more complex. nosing individuals, but also about diagnosing institutions and
Hoover’s analysis of the social diagnosis of this condition builds on organizations; and it is simultaneously a description of our analytic
the community-based participatory research by the laypeople and approach and a prescription for how to intervene. Social diagnosis
traditional healers of Akwesasne, in alliance with university can be an interesting tool for sociologists in various specialties
scholars and environmental health scientists, and implicates indi- within the discipline, as well as researchers outside the discipline.
vidual, social and cultural, and body-politic disease contributors. For example, environmental sociologists examining a disease such
Such analysis informs us that by the time it reaches the body politic, as asthma can take students on toxic tours in order to show the
biological disease goes to the core of the social fabric, and warrants neighborhood factors and pollution sources related to asthma.
an overall restructuring of power, capacity, and community. Social diagnosis can also be applied to medical history and science,
Further, we see that struggles over diagnosis are simultaneously technology, and society analyses of disease concepts and medical
struggles over causation. In this light, we can understand the multi- practices. The social diagnosis approach offers valuable lessons for
temporality of diagnosis: it is not only about the present, where physicians and other health professionals. In particular, the cursory
people seek knowledge about the symptoms they experience. It is instruction in occupational and environmental medicine in medical
also about the past, whereby people seek the causes of problems school can be countered through showing professionals how to ask
that led to a current diagnosis. As well, it is about the future, where appropriate questions about environmental and occupational
the medical and social sequelae of the diagnosis reside along with exposure. ‘Narrative medicine,’ formulated by Rita Charon (2006),
the treatment and prognosis. teaches medical students and physicians to attend to the totality of
life experience through eliciting and listening to patient stories, in
Conclusion order to more thoroughly diagnose them. Pediatrician Rosalind
Wright diagnoses asthma as being exacerbated by violence at home
Studying diagnosis provides a window into many components and in inner-city neighborhoods (Wright & Steinbach, 2001). This
of health and illness, and presents an organizing configuration and leads her to seek intervention strategies aimed at reducing violence
master frame. Our expansion into understanding and elaborating exposure, reducing stress, and counseling victims, in addition to
on social diagnosis makes this broader framework more applicable more traditional asthma treatment. At a preventive level, she urges
to an even greater number of research arenas. The act of diagnosing policy directions that address the social, economic, and political
an illness is important on multiple levels. It is about an individual’s factors that contribute to crime and violence.
relationship to the illness or act of diagnosis, the collectivity of Social diagnosis as a concept may not seem new to sociology,
people who suffer from an illness, and the larger social structures but it has yet to be developed into an enunciated framework and
that influence the illness and its diagnosis. In other words, it is program for research and/or action. For example, sociologist Eric
about locating an individual and a group in relation to key social Klinenberg’s account of the 1995 Chicago heat wave introduces the
structures. notion of social autopsy by effectively conducting a post-mortem of
In this paper, we have sought to understand the unique context the natural disaster and the various social factors that affected its
in which social diagnoses are formedda sociology of social diag- victims (2002). In doing so, Klinenberg provides a social diagnosis
nosis. To reiterate, social diagnosis is social in that it considers both of the heat wave, citing social isolation as one of the main causes
larger social structures, as well as the various social actors which and prescribing changes in the social structure to prevent relapse.
contribute to the diagnosis. In other words, a broad range of social This could serve as a very potent framework for sociologists and
factors goes into the making of a diagnosis, which is carried out by practitioners alike to carefully and systematically consider those
a myriad of social actors. The diagnosing of individuals can allow for social factors that play a crucial role in health. Also, while medical
the broader diagnosis of a group of illness sufferers, and an even sociology recognizes many extra-medical factors, the environ-
broader diagnosing of communities, as the Akwesasne example mental factors so important today have not been widely consid-
clearly illustrates. From here, we have drawn five key lessons which ered. Hence, there are still lessons to be learned about the
will not provide a one-size-fits-all framework, but will help prag- multi-factorial causes of morbidity and mortality. Sociologists
matically identify the role social diagnosis can play across many also continue to face uncertainty in knowing which social factors
different situations and among different constellations of actors: they ought to focus their attention on. Further, clinical examples
such as those above may seem logical to medical sociologists, but
1) Social diagnosis moves beyond individual-level explanations they are not generally accepted in the world of medicine. If medical
for health outcomes; sociologists work with clinicians and public health practitioners,
P. Brown et al. / Social Science & Medicine 73 (2011) 939e943 943

they may be able to jointly develop effective ways to use social Hoover, E. (2010). Local food production and community illness narratives: responses
to environmental contamination in the Mohawk community of Akwesasne. PhD
diagnosis for both treatment and prevention.
Dissertation: Anthropology Department. Providence: Brown University.
Kawachi, I., Kennedy, B., & Wilkinson, R. (Eds.). (1999). The society and population
health reader: Income inequality and health. New York: The New Press.
Acknowledgments Klinenberg, E. (2002). Heat wave: A social autopsy of disaster in Chicago. Chicago: The
University of Chicago Press.
Krimsky, S. (2002). Hormonal chaos: The scientific and social origins of the
We are grateful to David Ciplet, Alissa Cordner, Leah Greenblum, environmental endocrine hypothesis. Baltimore: Johns Hopkins University Press.
Bindu Pannikar, and Allison Waters for comments. LaVeist, T. (Ed.). (2002). Race, ethnicity, and health: A public health reader. New York:
Jossey-Bass.
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