HST209H1F

Introduction to Health:
Determinants of Health and
Health Care

Fall 2022
Health Studies Program
University College
University of Toronto

Instructor: Anthony Lombardo, PhD 1

October 3, 2022
● Radar
○ Assignment #2 preparations
○ Mid-Term Test info
● Paradigms of Health
○ Sociology
○ Political Economy of Health
● Tutorial Activity

2
Recap 3
Recap

4
Paradigms of
Health 5
Sociology

6
The Discipline of Sociology

● Studying human society

● Macro level
○ Social structures
○ Social institutions

● Micro level
○ Individual and group interactions

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 7
Sociology, Medicine and Health

● Sociology in medicine
○ Study of health-related problems, experiences, etc.

● Sociology of medicine
○ Study of health care organization, medical settings

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 8
Sociology, Medicine and Health
Sociology of Health & Illness Sociology of Medicine
● Distribution of disease and death ● Organization of healthcare system
● Socio-demographic explanations ● Medico-industrial complex
for disease and death ● Class, patriarchy and sexism in the
● Experiencing and talking about organization of healthcare
disease and death

Juanne Nancarrow Clark, Health, Illness, and Medicine in Canada, 6th edition, Toronto, Oxford, 2012. Adapted from Table 1.1, p. 4.
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Exercise: Sociology of / in medicine

www.menti.com | 7960 7723

10
Approaches to Sociology of Health

● Functionalism
● Symbolic interactionism
● Materialism (Conflict theory)
● Feminism
● Anti-racism / Post-colonialism
● Postmodernism

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 11
Functionalist Approaches

● Structural functionialism
○ All social institutions, structures, etc., have a “function” for society
○ “Organic” model of society

○ Critiques?

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 12
Interactionist & Constructionist
Approaches to Health
● How do individuals interact?
● How do they create meaning through interaction?

● “Definition of the situation”

○ The Thomas dictum: What people define as ‘real’ becomes real in its consequences (WI Thomas)

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 13
Interactionist & Constructionist
Approaches to Health
● Erving Goffman
○ Total institutions
○ Stigma
○ Labelling theory

● “Biographical disruptions”
○ Adjusting ‘self’ around illness

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 14
Interactionist & Constructionist
Approaches to Health
● Interactionism and health care
○ “Cloak of competence” (Haas & Shaffir)
■ Impression management to display ‘competence’ and ‘skill’
○ Having Epilepsy (Schneider & Conrad)
■ Centrality of uncertainty
■ Controlling symptoms
■ Changing relationships

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63; Juanne Nancarrow Clark, Health, Illness, and
Medicine in Canada, 6th edition, Toronto, Oxford, 2012.
15
Interactionist & Constructionist
Approaches to Health
● Social Construction of Reality
○ Berger & Luckmann
○ Diseases as “political accomplishments”

● Medicine as social control

○ “Medicalization” of disease as a means to exert control

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 16
Interactionist & Constructionist
Approaches to Health
● “Medicalization” (Conrad & Schneider)
○ Behaviours come to be defined as “illness” or “disease”
○ Behaviour first defined as deviant
○ Prospecting: announcement of “finding”
○ Claims-making: medical/non-medical interests promote new medical designation
○ Legitimacy: official designation
○ Institutionalization: official medical classification; treatment organizations

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 17
Materialist (Conflict) Approaches

● Macro-level, focus on conflict

○ Who controls production?
○ Marxist analyses
■ Capitalist class vs. proletariat

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 18
Materialist (Conflict) Approaches

● Navarro: Social production of disease

○ Profit vs. safety
○ Nature of capitalist work produces disease
■ Intensification of work
■ Fragmentation of work
■ Alienation from work
○ Physical, chemical, biological dangerous at work places
■ Particularly among lower-skilled jobs

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 19
Feminist Approaches to Health

● Patriarchy
○ Male-dominated nature of society
● Concern with gender inequalities

● Women not adequately represented in other forms of social theory

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 20
Feminist Approaches to Health

● Medicalization of women and women’s bodies

○ Hospitalization during childbirth

● Discovery of “menopause”

● Women in healthcare system

○ Sub-ordination
○ Midwifery

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 21
Anti-Racism / Post-Colonial
Approaches
● Impact of race on health/health care

● Structural determinants of racism

● Post-colonialism
○ Race & “the other”
○ Giving “the other” a voice

● Intersectionality theory

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 22
Anti-Racism / Post-Colonial
Approaches
● Focus on “racialized” experiences of
○ Care recipients
○ Care providers

● Experiences of groups and health systems

○ Canadian First Nations peoples
○ Loss of health human resources in developing nations

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 23
Postmodern
Approaches to
Health

https://doi.org/10.1016/B0-08-043076-7/01034-2

24
Postmodern
Approaches to
Health

https://doi.org/10.1016/B0-08-043076-7/01942-2

25
Postmodern Approaches to Health

● Postmodernism / post-structuralism
○ No objective “truth” to be known
○ Subjective knowledges

● Foucault – “government of the body”

○ Governmentality
■ Medicine as governing the body
○ Techniques of the self
○ “New” public health (lifestyle risks)

Ivy Lynn Bourgeault, “Sociological Perspectives on Health and Health Care,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical
Perspectives on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 41-63. 26
Postmodern Approaches to Health

● Fox, N. J. (2016). Health sociology from post-structuralism to the new

materialisms. Health, 20(1), 62–74. https://www.jstor.org/stable/26652333

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Political Economy
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Political Economy of Health

● Political economy…
○ State/governance
○ Economy
○ Civil society
● Issues considered…
○ How is wealth produced?
○ How is wealth distributed?
○ Who has power in society? Why is it that way?
○ Who controls resources? The state or the markets?
Dennis Raphael and Toba Bryant, “Maintaining population health in a period of welfare state decline: Political economy as the missing
dimension in health promotion theory and practice,” Promotion and Education, vol. 14, no. 4 (2006): 236-261.
 30

Political Economy of Health

● With respect to health…

○ Production & distribution of resources are determinants of the health of populations
● Key issues
○ Income distribution
○ Employment conditions
○ Availability of social and health services

Dennis Raphael and Toba Bryant, “Maintaining population health in a period of welfare state decline: Political economy as the missing
dimension in health promotion theory and practice,” Promotion and Education, vol. 14, no. 4 (2006): 236-261.
Income Inequality & Health
● Kennedy, Kawachi & Prothrow-Stith (1996)
○ Income inequality in US states
■ Increased chances of mortality
● Controlling for poverty and smoking
● Kaplan et al. (1996)
○ Income inequality in US states
■ Increased chances of mortality
■ Homicide/violent crimes; smoking; physical inactivity; higher rates of
unemployment, imprisonment
● Lynch et al. (1998)
○ Income inequality in 282 metropolitan areas in the US
■ Increased mortality
Bruce P. Kennedy et al., “Income distribution and mortality: Cross sectional ecological study of the Robin Hood Index in the United States,” BMJ, vol. 312, pp. 1004-1007, 1996; George A.
Kaplan et al., “Inequality in income and mortality in the United States: Analysis of mortality and potential pathways,” BMJ, vol. 312, pp. 999-1003, 1996; John W. Lynch et al., “Income 31
inequality and mortality in metropolitan areas of the United States,” American Journal of Public Health, vol. 88, no. 7, pp. 1074-1080, 1998.
Evidence

●⬆ income inequality, ⬆ mortality

● Why might this be the case?

Ichiro Kawachi, et al., “Social Capital, Income Inequality, and Mortality,” American Journal of Public Health, vol. 87, no. 9, 1491-1498. 32
Pathways/Mechanisms

● Disinvestment in human capital

○ Higher income inequality, lower spending on public services
○ Disparity of interests in rich vs. poor
○ Lower taxes, reduced public services
○ Less opportunity for the poor to improve their situations

Ichiro Kawachi and Bruce P. Kennedy, “Income Inequality and Health: Pathways and Mechanisms,” Health Services Research, vol. 34, no. 1 (1999,
Part II): 215-227. 33
Evidence: Disinvestment in Human
Capital
● State-level comparisons of income inequality and all cause mortality
● Significant correlation (r=0.62) between income inequality and all-cause
mortality

● Also correlated with…

○ Homicide rate
○ Violent crime
○ Low birth weight

George A. Kaplan et al., “Inequality in income and mortality in the United States: Analysis of mortality and potential pathways,” British Medical
Journal, vol. 312 (1996): 999-1003. 34
 35

Evidence: Disinvestment in Human

Capital
● States with greater inequality had higher rates of…
○ Unemployment
○ Incarceration
○ Social assistance
○ Medically uninsured
● States with greater inequality…
○ Smaller proportion spent on education
○ Poorer educational outcomes
■ Reading/proficiency in math
■ Lower completion rates for high school
George A. Kaplan et al., “Inequality in income and mortality in the United States: Analysis of mortality and potential pathways,” British Medical
Journal, vol. 312 (1996): 999-1003.
Pathways/Mechanisms

● Eroding social capital

○ Disrupting the social fabric
○ Latent social conflict, distrust between individuals
○ Low confidence in public institutions
○ Less voice of the “poor” in politics
○ Fewer policies to protect most vulnerable
○ Less generous states = less hospitable environments for the poor

Ichiro Kawachi and Bruce P. Kennedy, “Income Inequality and Health: Pathways and Mechanisms,” Health Services Research, vol. 34, no. 1 (1999,
Part II): 215-227. 36
 37

Evidence: Erosion of Social Capital

● ⬆ income inequality, ⬆ mortality

● Income inequality, social capital and mortality

○ ⬆ income inequality, ⬇ social capital, ⬆ mortality
● Kawachi et al. (1997)
○ General Social Survey, 1990 US Census, 1990 Compressed Mortality Files

Ichiro Kawachi, et al., “Social Capital, Income Inequality, and Mortality,” American Journal of Public Health, vol. 87, no. 9, 1491-1498.
 38

Evidence: Erosion of Social Capital

● Inverse relationship between degree of income inequality and group

membership

● Income inequality associated with lack of social trust

● States with high levels of social mistrust had higher rates of total mortality

Ichiro Kawachi, et al., “Social Capital, Income Inequality, and Mortality,” American Journal of Public Health, vol. 87, no. 9, 1491-1498.
 39

Evidence: Erosion of Social Capital

● Lower levels of social trust associated with higher rates of most major causes
of death
○ Heart disease, cancer, cerebrovascular disease, unintentional injury, infant mortality
● Income inequality ➡ increased mortality, mediated by decreased social
capital

Ichiro Kawachi, et al., “Social Capital, Income Inequality, and Mortality,” American Journal of Public Health, vol. 87, no. 9, 1491-1498.
Pathways/Mechanisms

● Theory of social comparison

○ Focus on relative deprivation
○ Lifestyle “cultural consonance”
■ Achieving what is accepted in culture as “lifestyle”
○ Lower “cultural consonance,” higher rates of systolic blood pressure
■ (work by Dressler, 1996, 1998)
○ Stress of “competition” lifestyle (frustrated expectations)

Ichiro Kawachi and Bruce P. Kennedy, “Income Inequality and Health: Pathways and Mechanisms,” Health Services Research, vol. 34, no. 1 (1999,
Part II): 215-227. 40
 41

Evidence: Social Comparison

● Shared model of “acceptable living” in communities

○ Defined set of lifestyle items
○ Strive to attain those items/lifestyles
● Adverse health effects from failing to meet these ideals
● US and Brazil –
○ Departing from “cultural consonance” strongest predictor of systolic blood pressure

William Dressler, “Culture and blood pressure: Using consensus analysis to create measurement,” Cultural Anthropology Methods, vol. 8, no. 3
(1996): 6-8
 42

Political Economy of Health

● Social Democratic ● Liberal

○ Inequality addressed through ○ Few redistributive policies;
social programs lower social expenditures
○ Universal health care coverage ○ Social programs tend to be
& social benefits means-tested
○ Sweden, Norway, Denmark, ○ UK, Ireland, Canada, USA
Finland, Austria (0.225) (0.320/0.372[US])

● Christian Democratic ● Conservative/Fascist

○ Fewer redistributive policies ○ Underdeveloped welfare
○ Universal health care coverage states; poor social program
■ But much emphasis on family ○ Very unequal income
caregiving (ie, private vs. distribution
public $$$) ○ Implementation of democracy
○ Italy, Netherlands, West (1970s) improved these
Germany, Belgium, France situations
(0.306) ○ Spain, Portugal, Greece (0.423)

Vincente Navarro, et al., “Politics and Health Outcomes,” Lancet, vol. 368 (2006): 1033-1035.
 43

Political Economy of Health

 44

Political Economy of Health

Correlation between dependent variable (infant mortality rate) and

independent variables in various years

* Significant at 90%.
† Significant at 95%.

Adapted from Vincente Navarro, et al., “Politics and Health Outcomes,” Lancet, vol. 368 (2006): 1035, Table 1.
Tutorial Activity
Thinking Political Economy

● Alcohol labelling in the Yukon Group Article

● Grenfell Tower fire (London, 2017) 1/7 New booze labels...

● How do these articles illustrate a political 2/8 Liquor industry...

economic approach?
3/9 Yukon seeks...
Padlet:
https://utoronto.padlet.org/anthonylombardo/j2 4 / 10 Political kindling...
i6x909r2bwirxa

5 / 11 Economic system...

6 / 12 Yes, the Grenfell...

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