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Health, illness and medicine
Introduction: the social basis of health, illness and medicine 356 Theoretical approaches 359
Parsonsian functionalism and ‘the sick role’ 359 Symbolic interactionism and the social construction of illness 360 Marxist theory 362 Feminist accounts 364 Foucauldian analysis 365 Combining perspectives: Turner’s contribution 366
The medical profession and the power of orthodox medicine 367 Health inequalities 373
G G G
The contemporary health care system 374 The globalisation of health, illness and medicine 377
Chapter summary 379
simply biological descriptions of the state of our bodies. A more reﬁned version of this common-sense view underlies the long-standing biomedical model of disease.356 X INTRODUCTORY SOCIOLOGY X Aims of the chapter Health and illness are consistent human preoccupations. and sociologists are not immune to this fascination with the state of our bodies. G G G G This model has dominated medical practice because it has been seen to work. experience. Disease is a temporary organic state that can be eradicated – cured – by medical intervention. definition and treatment of illness cannot be understood simply in physical or biological terms. illness and medicine. who then becomes the object of treatment. The search for the fundamental – that . Health and illness are. illness and their medical management are part of the wider cultural system and are closely associated with social control by professions and the state. Disease is an organic condition: non-organic factors associated with the human mind are considered unimportant or are ignored altogether in the search for biological causes of pathological symptoms. It is based on a technically powerful science that has made a massive contribution to key areas of health (for example. claiming for ‘the social’ more than can be credibly accepted. By the end of this chapter. We show how the distribution. surely. and the genetic mapping of the body is being undertaken through the Human Genome Project. Disease is treated in a medical environment – a surgery or a hospital – away from the site where the symptoms ﬁrst appeared. which is based on the following assumptions: G Biomedical model A model of disease and illness that regards them as the consequence of certain malfunctions of the human body. you should have an understanding of the following concepts: G G G G The sick role The clinical gaze Epidemiology Iatrogenesis G G G G The biomedical model Total institution Labelling theory Professionalisation X Introduction: the social basis of health. vaccination). Health. illness and medicine To say that health and illness have a social basis may at ﬁrst seem to be an example of sociological arrogance. This chapter introduces you to the main sociological approaches to health. Disease is treated after the symptoms appear – the application of medicine is a reactive healing process. Disease is experienced by a sick individual. we’re ill. The anatomical and neurophysiological structures of the body have been mapped out. When we’re ill. The sociology of medicine also has strong links to analyses of the sociology of the body.
on the other hand. Distinguishing between acute (short-term) and chronic (longterm) illnesses. This distancing from the patient is part of the rationality of medical practice. about critical inspection. Instead. pp. ” Moreover. the medical gaze – has brought considerable power and prestige to the medical profession. not tradition.. QUESTION What do you feel about the last interaction you had with your doctor? Do any of the above observations about the power and status of the doctor vis-à-vis the patient ring true for you? . genetic – basis of human pathology is on. inasmuch as it has depended on the development over the past two centuries of a powerful. Because of its successes medicine also discharges people into illness. A cure in the original sense of medicine becomes more and more the exception. Beck (1992) points out that the improved capacity to diagnose illnesses has not necessarily been accompanied by ‘the presence or even the prospect of any effective measures to treat them’. is. many of whom may never meet the patient in the ﬂesh. as in the global elimination of smallpox. clinical instruments – ranging from the stethoscope to NMR (nuclear magnetic resonance imaging) – are used to expose deep-seated disease. . rose in the same period from 46 to over 80%. It also means that – by means of patients’ records. not folk beliefs. experimentally based medical analysis of the structure and function of the body and the agents that attack or weaken it. I L L N E S S A N D M E D I C I N E X 357 Medical gaze A concept employed by Foucault (1977a) to denote the power of modern medicine to define the human body. not customs and mistaken notions of healing. This application of ‘rational medicine’ has also reduced reliance on patients’ own accounts of their illness (Stacey. as well as an important device for cultivating a mystique of professional expertise. X-rays.. The die of chronic illnesses. which it is able to diagnose with its high technology. 1989). and. 87) notes. scientiﬁc medicine has effectively displaced folk or lay medicine. ‘the criteria of referral are continuously being adjusted to keep specialists in work’. Unlike in the eighteenth and nineteenth centuries. 204–5) that: of 40 out died of acute illnesses. Zeneca and Merck. C O N N E C T I O N S For a description of the growth of rationality in the modern world.. about control through scientiﬁc and technical regulation of the body. . AIDS or Alzheimer’s disease. pages 30–3. “At the start onlythis century.causes ofof 100 patientsproportion of those who In 1980 these constituted 1% of the mortality.H E A LT H . the growing technical sophistication of medicine exposes patients to an array of equipment and therapeutic techniques that have to be used frequently to justify their expense. p. Modernity is about expertise. see Chapter 2. National governments and international agencies such as the World Health Organisation (WHO) proclaim their long-term health goal to be the eradication of disease. During the course of this. whether the target is cancer. The biomedical model also underlies the ofﬁcial deﬁnition of health and disease adopted by state and international authorities. It has also established a large and proﬁtable market for major pharmaceutical companies such as Glaxo-Wellcome. Yet this is not the expression solely of a failure. The rational application of medical science is therefore a hallmark of modernity... as Richman (1987. he points out (ibid. This ever closer and more sophisticated inspection of the body – or as Foucault (1977a) would say. scans and chromosomal proﬁles – cases can be handled by teams of doctors. Sometimes they have been successful. doctors rarely rely on descriptions by or the demeanour of the patient for diagnosis.
so that social or moral – rather than biomedical – repair is needed (Allen. according to the biomedical model. performance of ‘the sick role’. highly context-speciﬁc. historical and cultural reasons for the rise to dominance of medicine – especially the biomedical model – in the TA B L E 1 3 . it is often calmed by a good pull on the ﬁrst cigarette of the day. Among a household of smokers. Yet the power and status of the medical profession and the health industry in general should not deﬂect us from asking about the social basis of health and illness. anthropologists and historians have described the social basis of health and illness in a wide range of studies. rather than with exploring its organic manifestation in individual bodies. C O N N E C T I O N S Chapter 16. should force us to go to the doctor or take a pill are not necessarily seen as signs of illness by people themselves. 1 Ratio of symptom episodes to consultations Headache Backache Emotional problem Abdominal pain Sore throat Pain in chest 184:1 52:1 46:1 28:1 18:1 14:1 Source: Banks et al. .358 X INTRODUCTORY SOCIOLOGY Holistic Involving a focus on the whole rather than on specific parts or aspects. pages 456–60. The sociology of medicine is concerned with exploring the social. Studies in the US have shown that patients present themselves to ‘the medical gaze’ more rarely than doctors would expect or like. 1992) Alternative or complementary remedies for ill-health often take a holistic approach to understanding the cause of illness and its remedy. In short. including ethnographies of speciﬁc communities. the position of medical professionals is itself a result of the socially institutionalised power to deﬁne the experience of being ‘ill’ and decide what treatment is required. In fact. illness is often associated with failure to deal properly with interpersonal relations. Table 13. requiring consultation with a doctor and becoming a patient. Sociologists. More reﬂective doctors will acknowledge that their deﬁnitions of health and illness are not always shared by their patients and therefore have to be promoted through education. the wider creation of medical belief systems and the relationship between these and the exercise of power and social control. for example. the morning ‘smoker’s cough’ is unlikely to be seen as abnormal or a sign of ill-health: indeed. Symptoms that. They have explored issues of health care. the construction of mental illness as a disease. Among many Westerners. dynamic and subject to change. there is no clear-cut relationship between the existence of a physical or emotional feeling and the judgement that this indicates illness (that it is a ‘symptom’). people’s perception of health and illness is culturally variable.1 shows the relatively infrequent rate at which people visit a doctor for a range of symptoms. Among the Madi of Uganda. The sociology of health and illness is concerned with the social origins of and inﬂuences on disease. socialisation and expensive advertising. a suntan suggests health and good looks rather than leading to wrinkled skin or skin cancer. (1975). Crucially. considers the techniques of ethnography as a way of exploring the social world.
Foucauldian theory concentrates on the dominant medical discourse. The argument here is that illness is a social accomplishment among actors rather than just a matter of physiological malfunction. Symbolic interactionism is concerned with examining the interaction between the different role players in the health and illness drama. Parsonsian functionalism and ‘the sick role’ Although Parsons (1951) was interested in several aspects of the management of illness. In short. G G G . X Theoretical approaches The sociology of health and illness is informed by ﬁve theoretical traditions: G G G G G Parsonsian functionalism looks at the role the sick person plays in society. The main focus is on how the deﬁnition and treatment of health and illness are inﬂuenced by the nature of economic activity in a capitalist society. it amounts to a form of deviance. This discourse provides subjects in modern societies with the vocabulary through which their medical needs and remedies are deﬁned. Four features deﬁne the sick role: G Sick people are legitimately exempted from normal social responsibilities associated with work and the family. he is best remembered for his emphasis on the social importance of the sick role. Since being sick means choosing to withdraw from the normal patterns of social behaviour. Feminist theory explores the gendered nature of the deﬁnition of illness and treatment of patients. Marxist theory is concerned with the relationship between health and illness and capitalist social organisation. The role of medicine is to regulate and control those who have decided they are sick so that they can return to their normal tasks and responsibilities. which has constructed deﬁnitions of normality (health) and deviance (sickness). people have to decide that they are sick and in need of treatment. I L L N E S S A N D M E D I C I N E X 359 deﬁnition and treatment of illness. Parsons stressed the motivation involved in being sick and getting better. Sick people cannot make themselves better – they need professional help. Sick people are obliged to want to get better – being sick is only tolerated if there is a desire to return to health. The focus is on how illness and the subjective experience of being sick are constructed through the doctor–patient exchange. and hence the efﬁcient functioning of the social system depends on the sick being managed and controlled. since the way in which professional (or orthodox) medicine deﬁnes and manages illness reﬂects wider social dynamics that shape the perception and experience of disease. The focus is on how being ill is given a speciﬁc form in human societies so that the social system’s stability and cohesion can be maintained. These ﬁelds are closely related. the sick role enquires a commitment on the part of those who feel unwell to return to normality as soon as possible. Medicine is not just about medicine as it is conventionally understood. Foucauldian theorists also argue that medical discourse plays an important role in the management of individual bodies (what Foucault called ‘anatomopolitics’) and bodies en masse (bio-politics). Sick people are therefore expected to seek professional treatment.H E A LT H . Its main concern is the way in which medical treatment involves male control over women’s bodies and identities. That is. but also about wider structures of power and control. The source and beneﬁciary of this discourse is the medical profession.
Second. For this reason epidemiological statistics on the distribution of illnesses. a number of researchers have pointed out that arrival at the doctor’s surgery is often the last stage in the construction of sickness. which has prompted sociologists from the symbolic interactionist school to look more closely at the interaction between doctor and patient. The sociological question here is why it is that some sick people and their illness remain under-reported or are dealt with primarily within the lay arena. age. Despite these criticisms. Learning to become a social being means learning to achieve control over this process by managing the impressions others have of us (see Chapter 18). Doctors in UK casualty wards have a private language for classifying newly arrived patients. Instead. Many patients cope with illness by deﬁning it as a ‘job’. but unfortunately not dead yet’). Conformity to these codes gives doctors unusual rights – the right of authority over their patients’ health. should be treated with caution. Parsons’ notion of the sick role enabled exploration of the construction and career or ‘occupation’ of being ill (Herzlich. According to Pollock (1998). applying their skill and expertise according to professional codes of conduct. . Parsons assumes that patients will be sufﬁciently knowledgeable about and sensitive to their condition to know that they should consult a doctor. These are just a few examples of the variation in practice among doctors. This creative capacity is evident when we play the role of patient in our encounters with health-care practitioners. cooperation with others (doctors and kin) and sharing information about the state of the illness. For example. while similar problems among male patients are viewed as the product of work-related stress (MacIntyre and Oldham. as they are seen by others as having no control over their illness: the notion of positive coping is not seen as credible in their case. As for the role of doctors. there was a growth in chronic rather than acute conditions. This example tells us much about the interactive nature of illness and the social accounting processes surrounding it. but will be naive and compliant once inside the surgery. First. In return. doctor–patient interactions do not follow the script laid out by Parsons (1951). Bundy’ (‘Totally fucked. Given this interpretive element of the social encounter. There is also a tendency to treat female patients’ problems as ‘typical’ feminine neuroses and complaints. but research shows that the class. identity is created through interaction with others. 1973. it is perfectly possible to be a sick person without becoming a patient. Third. higher social classes are given more consultation time and a more comprehensive explanation of their illness than are lower classes. and the right to obtain personal details from their patients. including the acronym ‘T.360 X INTRODUCTORY SOCIOLOGY Epidemiology The study of patterns of disease. according to Scambler (1991). this ‘illness as a job’ option is not available. 1988). the majority of patients consult widely with lay (non-medical) contacts before deciding to visit the doctor. Pollock. to be successfully managed by hard work. Symbolic interactionism and the social construction of illness According to the symbolic interactionism thesis. gender and ethnicity of patients can have a considerable bearing on the kind of treatment provided. but during the twentieth century. F. which derive from doctor–patient consultations. for people suffering from chronic forms of mental illness such as schizophrenia. There have been a number of criticisms of Parsons’ model. Thus. while others are not. 1977). in return for the trust placed in them. doctors are expected to treat all patients equally. Practitioners also attempt to create impressions of themselves for us. doctors are obliged to act in the best interests of their patients. For instance. we should expect a considerable variation in the interactive play. the right to examine their patients’ bodies. it assumes that recovery is always possible.
Stewart and Roter (1989) have constructed a similar classiﬁcation. a process that starts as soon as they are admitted. Labelling Describes the process where socially defined identities are imposed or adopted. This shows the potential for conﬂict between medical practitioners and patients. a cancer patient may be labelled a cancer patient above all else. Likewise. too. as they are responsible for the everyday management of their condition. Following the classic analysis of institutionalisation by Erving Goffman (1968). market-based health care) with that where the doctor dominates. Such labels can result in the individual being trapped in that identity (see stigmatise). Most studies show that the power element in doctor–patient relations is signiﬁcant. It is at this stage – of ‘self-realisation’ – that the labellers. ﬁnds it impossible not to believe in the reality of the illness. especially deviant identities. convents and so on. . such as prisons and mental hospitals. especially in private. Interactionist analysis draws attention to the often overwhelming inﬂuence of the stigmatic label.H E A LT H . (1973) have shown how difﬁcult it is to resist the imposition of a label for those deﬁned as mentally ill. but some do resist and attempt to maintain their personal autonomy and identity. whether through medical diagnosis or through the way in which a sick person’s friends. the illness to which the label is attached may even be interpreted as a sign of personal weakness or culpability (Sontag.’ QUESTION Have you ever manipulated an illness for your own ends. there is a labelling component in illness. interactionist research into hospital life often focuses on the claim that the hospital regime is designed to restrict the opportunity of patients to fashion their own identities. Lemert (1974) asserts that the imposition of a stigmatic label – especially that of being ‘mentally ill’ – is a serious assault on a person’s sense of self. preconceived notions about the state of being elderly discount the way they really are. with doctor-centred interactions being the most common. no matter how the sufferer tries to persuade others that he or she is still a friend. in the case of elderly people who are physically very ﬁt. Patients’ power to control their identity is reduced as much as possible. by refusing to comply rigidly with the ward rules. 1979). The end result is that the patient. a lover or a mother who just happens to have cancer. whether mentally ill or not. Most patients are compliant. for example. what part did the sick role or labelling play in this process? The power element in doctor–patient relations is particularly signiﬁcant when a patient is obliged to enter hospital. the more difﬁcult it is for the latter to resist the illness stigma. Horwitz (1977) has shown that the greater the social gap in terms of class and status between the labeller and the labelled. mental hospitals. Total institutions Employed by Goffman (1968). 53) suggests that the relationship between practitioner and patient moves between these two states during the various stages of an illness: ‘At an acute stage of illness it may be necessary or desirable for the doctor to be dominant. Such people are effectively being told that their (mental) capacity for selfknowledge is damaged and their feelings about themselves are probably delusory. I L L N E S S A N D M E D I C I N E X 361 Byrne and Long (1976) present a continuum of interactions. especially the medical staff. That is. such as taking more time off work than is strictly needed for recovery? If you have. p. start to feel hopeful about eventual recovery! Labelling can work in other ways. whereupon they become ‘difﬁcult patients’. Indeed. contrasting the situation where the patient dominates (as a consumer of medicine. Hospital life mirrors life in other total institutions such as prisons. For example. Conﬂict also arises from the power of others to impose their deﬁnition of ‘being ill’ on the patient. Rosenhan et al. exercising a strong paternalism over subordinate clients. For example. whereas at later stages it may be beneﬁcial for patients to be more actively involved. relatives and others treat him or her. Morgan (1997. this term refers to all institutions that assume total control over their inmates. with exclusively patient-centred communication at the one extreme and exclusively doctor-centred communication at the other.
p. Medicine is a major social institution. at the outpatient clinic or on hospital wards. the interactionist approach focuses on power relations in the construction and management of health and illness. it has become increasingly proﬁtable for two dominant capitalist interests: the ﬁnance sector. it is shaped by capitalist interests. However. We have to turn to other approaches to provide a theoretical explanation of such inequality. medical instruments and so on. see Chapter 18. Medicine now has an extensive wage-labour force (including employees in the pharmaceutical industry and related industrial sectors). This process is characteristic of (late) capitalism as a whole: ‘Monopoly capital invades. involving close relations between large ﬁrms and state agencies. Rather. 31): G G G Medicine has changed from an individual craft or skill to ‘corporate medicine’. Marxist theory is concerned with the way in which the dominant economic structure of society determines inequality and power. it explains power and inequality as functions of the relative strength of the personalities of the parties to the medical encounter. The state buys drugs and other equipment from large ﬁrms. Furthermore. their professional status has gradually been undermined as a result of administrative and managerial staff taking over responsibility for health care provision. 243). subsidises their research through university laboratories and maintains a large hospital infrastructure that requires their goods. in the surgery. notably Navarro (1985). through private insurance provision. Marxists also claim that health problems are closely tied to unhealthy and stressful work environments. interactionism offers neither a theory of power nor a theory of patterns of inequality. It draws attention to the unequal distribution of the resources available to health practitioners and patients. G These four processes mean that medicine has become a market commodity.. whether in home visits. Marxist theory As we have seen elsewhere. this does not mean it is free of capitalist inﬂuence. directs and dominates either directly (via the private sector) or indirectly (via the state) all areas of economic and social life’ (ibid. Rather than seeing health problems as the result of individual frailty or weakness. it is part of the medical– industrial–state complex. and the corporate sector. Marxist accounts of capitalist medicine have been developed by a number of sociologists and health policy analysts. p. The power to direct and exploit the medical system has been seized by large corporations that enjoy monopolistic control over related market sectors. pages 501–5.. The last point illustrates Marxists’ claim that just because medicine is organised as a national system of health care (as in the UK). that point to ‘the invasion of the house of medicine by capital’ (ibid. C O N N E C T I O N S For the main features of interactionism and criticisms levelled against it. as well as shaping the relations upon which the major social institutions are built.362 X INTRODUCTORY SOCIOLOGY In summary. they should be seen in terms of the unequal social structure and . or as he puts it. through the sale of drugs. Rather. to be bought and sold like any other product. Medical practitioners have become proletarianised. and in capitalist societies. there are four features that deﬁne medicine as capitalist. that is. According to Navarro. Medicine has become increasingly specialised and hierarchical.
The state’s response commercial pharmaceutical has been to deﬂect attacks on the medical–industrial–state complex by products? declaring that health problems are the problem of the individual. For example. However. Figure 13. arguing that sentiments. Despite a condition of ‘photodamage’ more and more money being spent on health care. of which medical care is a key part. the measures taken are ameliorative rather than solving people’s health problems. research has shown that they also reﬂect pressure on workers to complete tasks at speed in risk-laden environments (Tombs. Patterns of mortality and ill-health (morbidity) are closely related to occupation. chemicals and so on) are responsible for over 10 per cent of all male cancers. That is. injury and illness among workers. class. suggesting that these statistical levels represent the structural – and not the accidental – character of occupational injury and mortality. since in late capitalism there is never complete coincidence between the interests of powerful corporations and those of the state (see Chapter 3). more and more which can be treated with people are experiencing the system as ineffective. sion later in the chapter. the Marxist political economy of health Political economy needs to address how the diversity of capitalist societies relates to medicine. Marxists are accused of underplaying the genuinely labour. that is. the UK and Sweden. in that its growth of the natural ageing process or is matched by an increasing inability to meet society’s needs. the experience of illness and the state of being a patient. embraces the concepts of social despite the fact that all three societies are quite distinctively capitalist’ (ibid. Finally. 1990. p. as Turner (1987) argues. operates on a different basis in and division of each of these countries. allowing the state to reduce the burdensome cost of universal medical provision. In addition. ‘there are major differences between the USA.. the value The welfare state. heavy metals. Moreover. but argues that their primary purpose is to regulate the working classes and the popular masses. the professional process that has sub- . health and An approach that illness. While accidents at work may be regarded as the result of human error. Critics of the Marxist view of medicine focus more on its inadequacy than its practice of locating medicine ﬁrmly within capitalism. and moral progressive features of the health sector under contemporary capitalism. Moreover. this is to be expected in medicine as elsewhere. I L L N E S S A N D M E D I C I N E X 363 class disadvantages that are reproduced under capitalism. and in the UK there has been considerable underpolicing of sweatshops and similar workplaces. it should pay more attention to the dynamics of the medical process. to take out extensive (and expensive) private medical insurance. Wright. especially in the case of the industrial working class. According to the Marxist view. and that any difﬁculty coping with this is not the fault of the system but of the individual. 194).1 Are wrinkles part Navarro argues that medicine is in a state of crisis. Navarro (1986) does acknowledge that medical practitioners play a useful role in delivering health care. Health and Safety Executive reports show that it has been difﬁcult to reduce injury levels below a certain threshold. 1994). the Marxist account is criticised for downplaying the gendering of health and medicine. As he notes. such legislation can only be fully effective if it is policed properly. so reducing the overall contribution they make to the state’s GNP We shall return to this global dimen. since a reduced state budget will hit the secure drugs market enjoyed by the pharmaceutical industry. The danger for the state is that larger multinational corporations will seek secure markets and cheaper labour overseas. The individual must be taught to become a discerning consumer of medicine. industrial carcinogens (asbestos.H E A LT H . This latter strategy will cause problems for the medical–industrial complex. Legislation to control hazards in the workplace has been introduced over the years. and this has reduced the rate of death.
the site where most gendered interaction takes place. it has medicalised events that are natural to women. Not only was there little real beneﬁt in having a physician in attendance at child birth. over the past century. while disorders that can inhibit full movement and strenuous sporting activities are associated. an area where patriarchy is acute and the links between sexuality and reproduction are biologically and socially intertwined. the bulk of them are in paramedical or nursing jobs with poorer pay and occupational status. Jordanova (1989) has shown. whereas in the past religion played this role (see Chapter 15). including menstruation. will not bring about any major change. The sexual division of labour in medicine reﬂects the subordination of women. 1979) that is challenging the medical establishment and promoting a philosophy of self-care and healing by and for women. pregnancy had become a fully medicalised condition (Oakley. while welcome. C O N N E C T I O N S A general account of feminist theories is presented in Chapter 17. as they concern the body. there has emerged a feminist health movement (led by writers such as Ehrenreich. anxiety. Nor is it surprising that feminists have paid great attention to birth and maternity. Feminist accounts In general. Despite health matters being seen as closely tied to women’s caring. Hence. and especially the advertisements. It is not surprising that medicine. feminist analyses of inequality have focused on the construction and maintenance of female subordination. how the classiﬁcation of illness by gender is commonplace. This leads us to the feminist approach to health and illness. The feminist critique concentrates on the male-dominated medical profession and the way in which. a healthy body is tied to healthy sexuality and reproduction within the conﬁnes of lawful marriage.364 X INTRODUCTORY SOCIOLOGY ordinated women of all social class backgrounds to patriarchal medical control. textbooks and journals perpetuate the patriarchal attitude towards women. with masculinity’ (ibid. this does not mean that women have a high position in the medical hierarchy. but there is also evidence to show that physicians had little idea about the birth process and that medical intervention often endangered both mother and child. through an examination of medical journals and magazines. in the US by state legislation. metaphorically. means that the majority of obstetricians and gynaecologists are men – about 80 per cent in the US and about 85 per cent in the UK. Feminists argue that only by breaking with the malestream of orthodox medicine can women regain control over their bodies. Midwifery had gradually been excluded. Thus. p.. nurturing role in a patriarchal society. By the mid 1950s. For women. 144). Feminists believe that the gradual increase in the proportion of female physicians. both personally and professionally. pages 488–94. 1984). pregnancy and childbirth. Malestream Used to describe institutions or practices that are male dominated. For example. while many women work in medicine. Medical intervention in these areas – which in the past were handled by women themselves in conjunction with family and female friends – originally arose from the desire by the newly emerging medical profession to create a medical market. sleeplessness and migraine are likely to be associated with women. ‘Depression. since at medical schools they are indoctrinated with the same patriarchal attitudes as their male colleagues. health and illness have been central to this analysis. the regulation of women’s bodies by controlling their sexual expression and reproductive capacity is now conducted through medicine. This removal from women of control over their bodies. . Medical training. As Turner (1987) notes.
the clinic and everyday public hygiene. care and control and how this relates to the regulation of bodies and sexuality in wider society was also recognised by Foucault. Medicine cannot . diets and exercise as the modern forms of self-regulation and public regulation of our bodies. whose theory we consider next. reality and social behaviour. we have to see it as part of a wider social requirement for the regulation and surveillance of bodies. because it deﬁnes. They constituted powerful forms of social discourse. Foucault argued that medicine plays not merely a clinical but also a moral role. urban planning. penology and notably medicine – was central to the disciplining of people as public and private bodies. medical discourse and the medical profession that sustained it had displaced the religious. Foucault’s concept of discourse was central to his analysis. 37–8) suggests: replaced the as the custodian of social values: the panoply of “Put simply. The emergence of ‘rational’ modern disciplines – such as economics. especially with regard to ‘proper’ forms of sexual expression. the doctor has of regulationpriest ritual order of sacraments. This recounts the way in which medicine has played an increasingly important role in establishing a regimen of acceptable sexuality. He used the term bodies both in the physical sense of individuals’ bodies and in the more abstract sense of bodies of populations. the demand for regulation grew as society became more complex – especially as it became urbanised and brought people together in one large mass. According to Foucault. pp. discourses are ways of knowing about or of representing. In their different ways. This discourse ﬁrst appeared during the nineteenth century: ‘A medico-administrative knowledge begins to develop concerning society. as he described in his History of Sexuality (1977b). has to be understood within this broader context of public control. its conditions of life. places of worship and sanctuary) have been transferred through the evolution of scientiﬁc medicine to a panoptic collection of localised agencies of surveillance and control. Here the concept of ‘discipline’ is important. Foucauldian analysis Foucault (1977a) insisted that in order to understand the role of medicine in society. its health and sickness. For Foucault. Urban areas have both public and private ‘spaces’ that dictate appropriate behaviour for the bodies that occupy them. Foucault’s work on medicine requires us to relate analyses of medicine and the body to historical changes in the ways in which the regulation of bodies has been secured in society. I L L N E S S A N D M E D I C I N E X 365 The relation between health. The clerical gaze has been replaced by the clinical gaze. p. each of these disciplines legitimated forms of social control and regulation over people. which serve as the basic core for the “social economy” and the sociology of the 19th century’ (Foucault. ” Religious mortiﬁcation and denial of the body have been replaced by health regimes. As discussed in other chapters (especially Chapter 19). the places of vocaecclesiastical institutions (the tional training. secular medicine provided a powerful means of social discipline and control.H E A LT H . Scientiﬁc. 176). Medicine. its deﬁnition. clergy-based discourses that dominated in previous centuries. at both the micro (individual) and the macro (population) level. and especially the medicine of the asylum. the hospice for pilgrims. As Turner (1987. organises and controls human bodies from the cradle to the grave. 1980. the rise of preventive medicine. housing and habits. social medicine and community medicine has extended these agencies and regulation deeper and deeper into social life. Furthermore. and so giving some control over. Medical discourse is one of the most powerful discourses.
Marxists emphasise the political economy of health. Here. and this reﬂects the wider social structures of capitalism.. Each has something to contribute to the sociological analysis of health. Croft and Beresford (1998) have provided an example of this when looking at discourses on dying (Box 13. He begins by distinguishing between three levels of analysis – the individual. Source: Croft and Beresford (1998.366 X INTRODUCTORY SOCIOLOGY be seen merely as an activity associated with clinical healing. A high percentage of dying takes place in medical institutions. Feminists insist that gender should be incorporated into the analysis of role relations and the deﬁnition of health and illness. science. The response of the dominant medical discourse on dying is often unsympathetic at [the] individual level to the concerns and approach of its subjects. the medicalisation of the body has to be understood as a process of social control. Secondly. of hospitals and asylums) and the way in which professionals (doctors) deﬁne and regulate sickness and disease (whether physical or mental). and not facing or accepting that they are dying. For example. in that there is considerable inequality in the ways in which health and illness are deﬁned and managed. medical dominance in death and dying. . interactionism plays a valuable role in drawing attention to the perceptions that people (and patients) have of their illness. technology and wisdom. as they focus on different aspects of the same phenomena. Here. we concentrate on institutional dynamics (for example. is interpreted in negative terms of people being ‘in denial’. 107–8). the medical profession and associated medical research overcoming disease through skill.. 1 The discourse of dying [T]he following seem to be some of the key terms in which we are conventionally encouraged to conceive of death and dying. pp. [M]edical victory. But the emergence of new discourses from the disabled people’s and social service users’ movements have strongly challenged this tradition. Parsons (1951) suggests that illness and disease create structural and behavioural problems that society needs to resolve through normative. The dominant medical discourses on . interactionists stress how the deﬁnitions of illness and the appropriate behaviours surrounding it are elastic and precarious because they are constructed through interaction. Foucauldian analysis ties the issue of medical control to the question of how the individual and the wider collective body are subject to bio-social surveillance and regulation. the focus of some people who are dying on the life they have.1) B O X 1 3 . Turner (1987) considers them to be reconcilable. rule-governed role performances. This is linked to the medicalisation and technisation of death. Here. Finally... illness and medicine in society. rather than on addressing dying. yet this is coupled with a low priority of palliative care in medicine . and point to the institutionalised patriarchy that characterises the health care system. we are interested in the experience of illness and disease. knowledge. It is possible to argue that these discrete traditions cannot be merged into a single theoretical model. at the societal level. at the level of the social. we turn to the wider macro or systemic structures that pattern health care systems. At the level of the individual. However. the Parsonsian and more institutionally oriented interactionist analyses (such as that by Goffman) are appropriate.. Combining perspectives: Turner’s contribution The sociological perspectives discussed above are based on distinct theoretical assumptions about how best to understand health. In contrast. dying are deeply rooted in the scientism and rationalism of the nineteenth century. feminist . illness and medicine. the social and the societal..
where sexual and biological pathologies are explicitly interlinked. The establishment of control over professional work practices. Its roots lie in the general professionalisation of a number of occupational groups. The demand for the healing powers of medicine has always existed. Turner is particularly interested in understanding the social and societal management of the HIV virus. which took place at different rates in different ﬁelds (Rich. In the ﬁrst.H E A LT H . Wright points out that the dominance of orthodox medicine did not reﬂect superior technical or scientiﬁc . allowed it to control if not eliminate competition by other medical groups. G G In short. X Professionalisation The process by which the members of a particular occupation seek to establish a monopoly over its practice. analysis. especially those relating to sexuality. 1974). professions are skilled occupations with a relatively privileged position in the occupational hierarchy whose members employ an ideology of expertise and client service to legitimate their advantaged position. How did medicine become so powerful? To answer this question. 1975). Professional status can only develop when there is sufﬁcient demand for the skills in question (Johnston and Robbins. the current medical system is the product of three centuries of dominance by the Royal College of Physicians (RCP). such as the apothecary companies and guilds. He agrees with Foucault that we can distinguish between the body as an individual entity – as a person – and as a collective entity – as a population. I L L N E S S A N D M E D I C I N E X 367 Homophobia Hatred or fear of homosexuals (including lesbians). 237) describes the accommodation of these different perspectives within a single theory as a ‘strategy of inclusion’: ‘Rather than being forced to choose between [these] particular competing paradigms. whose monopolistic practices. typically based on formal university qualiﬁcations. 1987): G The creation and defence of a specialist body of knowledge. Professionalisation involved three related processes (Turner. one could see them as addressing very different issues at rather different levels’. The Western medical profession developed within two distinct contexts during the nineteenth century. ﬁrst in Germany and then in the US. The desires. The personal and public hygiene that those in dominant positions demand for the regulation and checking of the virus has both a biological and a moral form: hence the homophobic term ‘gay plague’. demands and pathologies of the body at both these levels are regulated. The establishment of control over a specialised client market and the exclusion of competitor groups from that market. Turner (1992. His strategy relies on tying the sociological analysis of medicine to the sociology of the body. medical research and career opportunities centred on the university. According to Wright (1979). this is done by limiting entry to those with certain qualifications and claiming that those who lack these qualifications do not possess the requisite expertise. The second context was that in England. p. we need to trace the evolution of the profession. but its professionalisation is much more recent. The medical profession and the power of orthodox medicine All the above perspectives highlight the power of the medical establishment. Typically. Marxist political economy and Foucault’s exploration of power and discourse are important. especially since the late nineteenth century. The international standing of German medicine is indicated by the fact that between 1870 and 1914. 15 000 Americans studied medicine in German universities and took the German model back to the US. Turner has built on these different traditions to produce an integrated theoretical approach. responsibilities and obligations while resisting control by managerial or bureaucratic staff. legitimated by royal charter and government legislation. where the role of clinical practitioner/teacher and researcher was formally established as a salaried occupation.
as scientiﬁc medicine might compromise their client-oriented practices and the patronage these attracted. which was seen . There was a growing demand for doctors by rich city dwellers and the new urban middle classes. early civil servants and so on). The welfare state provided further support for this two-tier specialist and general practice structure. and so on. Developments during the latter part of the nineteenth century consolidated this split between the specialised. p. and therefore its institutional base had to be built from scratch. doctors would use bleeding and purging in their treatment. the patient is referred back to his or her GP for the next step – be this the discontinuation of treatment or referral to another specialist. which guaranteed them a market among the poorer social groups to supplement their growing middle-class market in the cities. 110) notes. other professionals. Today in the UK. restricted the terms of entry to the profession and gave doctors a legally sanctioned monopoly. In contrast. in the US. There were no equivalents of the guilds and the Royal Colleges to provide a framework for the broader medical structure. so their present-day distinctions do not merely derive from market forces in the US and national health care in the UK. The most important factor in the professionalisation of medicine was the expansion of the medical market during the nineteenth century. New recruits to the profession were limited by the terms of entry. new technologies and the like. which the medical profession could help deliver. The culture of nineteenth-century and early-twentieth-century US medicine was in stark contrast to that of the UK. such as astrology.368 X INTRODUCTORY SOCIOLOGY practices compared with other forms of healing. neither of which were likely to have any beneﬁcial effect on the patient. they have more to do with the historical structure and character of the profession in the two countries and the distinct medical markets within which practitioners operated. hospitalbased elite and the larger number of general practitioners. There were striking differences between the British and US patterns of medical professionalisation. In the British case. one indication of which was the relative absence of general practitioners and a preponderance of specialists in the US. many doctors resisted them. using institutions such as universities and medical colleges. set the qualiﬁcations for registration. there was only a 5 per cent increase in the number of medical practitioners. In the latter. of urban prostitution and working-class slums). The result was the Medical Act of 1858. When more reliable and effective medical techniques were developed. there was hostility towards new techniques such as anaesthesia. while specialist consultants control hospital provision. Typically. Indeed. The two professional systems began to diverge as early as the turn of the twentieth century. surgeons and apothecaries provided care for the embryonic middle classes (merchants. the professional class structure that was so evident in British medicine was virtually absent. The position of the latter group was secured by the 1911 National Health Insurance Act. GPs control patients’ access to primary health care. so although the population of England and Wales grew by 30 per cent between 1861 and 1881. with a strong emphasis on competitive specialisation. There was also an increased demand for social regulation (for example. while the lesser number of elite practitioners attached to the Royal College (of Surgeons/Physicians) attended to the upper classes and acted as principal medical ofﬁcers for charitable hospitals catering to the very poor. which established the ﬁrst national register of recognised practitioners. As Rosemary Stevens (1980. The growth in demand for medical services caused key players such as the RCP to seek to consolidate their control – backed by the government – over the health market. formal medical practice can be traced back to the sixteenth century. when guilds of physicians. ‘American medicine was a profession without institutions’. Once seen by a specialist.
The power of the profession can be understood by considering the medicalisation of lay forms of coping with illness and natural physical processes. p. Ultrasound monitoring of pregnancy. see Chapter 8. p. 2 The medicalisation of pregnancy Common medical procedures associated with pregnancy: G G G G G G Hospital birth. The old tend to be treated as a homogeneous group by the biomedical model of declining health. with religion gradually ceding territory to the newly established psychiatric profession.’ C O N N E C T I O N S For a general discussion of the issue of power. I L L N E S S A N D M E D I C I N E X 369 as an affront to the professional skill of surgeons who were practised in the art of rapid and therefore relatively pain-free surgery. However. G G G . previously handled within the community. the social context of medical practice encouraged the many competing specialists to look to new treatments.H E A LT H . and to transmit tradition’. Whatever the historical variations in the professionalisation of medicine. especially by sociologists such as Freidson (1988) and Johnson (1972). Iron and vitamin supplements. This specialist competitive dynamic also encouraged much greater emphasis on research in the US than in the UK. they are redeﬁned as a form of illness open to medical intervention. ageing does not ﬁt the conventional biomedical ‘curative’ discourse. The ﬁrst is incorporating and redeﬁning lay approaches to illness and physical processes so that they fall under the ‘medical gaze’ – that is. 25) says: ‘The professional rhetoric relating to community service and altruism may be in many cases a signiﬁcant factor in moulding the practices of individual professionals. Regular ante-natal check-ups. Artificial rupture of the membranes. to conserve ceremony. the American physician Flexner (1910. Medicalisation can take three forms. in 1994 in the UK. such as ageing. 30) observed that research and clinical standards were poor in the UK. Vaginal examinations during pregnancy. who sought to lift the lid on client-oriented professional ethics that claimed to beneﬁt patients but were in fact occupational ideologies that enabled professionals to secure considerable autonomy and distance from their clients. Commenting on this difference in the earlier part of the twentieth century. techniques and therapies to demonstrate their specialist skills. Pharmacological induction of labour. As such. B O X 1 3 . the pressure to medicalise ageing is increasing because the necessary community and family structures are no longer in place to take on responsibility for the aged. As Johnson (1972. the power of the profession to control its position and reward in the labour market has been carefully documented. while the guild-based professional structure was ‘admirably calculated to protect honour and dignity. and this has remained broadly true ever since. Ageing is another area where medicalisation has occurred. In the US. Enemas or suppositories in the first stage of labour. whose number is growing rapidly: for example. pages 194–206. Deviant or unusual mental states that had been seen in communities as signs of witchcraft or possession (divine as well as evil) were gradually redeﬁned as psychiatric conditions. the ageing of the body is seen as incurable. Unlike other areas of medical discourse. over nine million were aged 65 or over. but it also clearly functions as a legitimation of professional privilege. Mental illness was medicalised in this way in the late eighteenth century. Shaving of the pubic hair during labour.
some have stressed the need for caution when evaluating the impact of medicine. According to Illich (1976. a former director of the UK Medical Research Council’s Epidemiology Unit. 17–18). Moreover. however. the beneﬁt of scientiﬁc medicine is challenged by the growing incidence of iatrogenic illness.. The results do not suggest that there is any medical gain in admission to hospital with coronary care units compared with treatment at home’ (ibid. 74). doctor-induced illness and disability. lay medical treatment still plays a part in all health care systems. Accelerated delivery of the placenta by injection of ergometrine and/or oxytocin and pulling on the cord. p. Cutting the umbilical cord immediately after birth. citing poor monitoring and the failure to conduct rigorous comparisons of one technique against any other. G G G G Birth in horizontal or semi-horizontal position. anti-viral agents and antibiotics are heralded as proof of the scientiﬁc progress of medical research and clinical practice. disability and anguish resulting from technical medical intervention now rival the morbidity due to trafﬁc and industrial accidents and even war-related activities. Illich’s strong attack on medicine might seem to be overstated. therapies. the personal responsibility of physicians is less clear. Source: Oakley (1979. The relationship between orthodox and alternative medicine in terms of patient involvement varies: some may always turn to alternative medicine when ill. in your opinion. The marginalisation of alternative medical therapies is the third aspect of medicalisation. Pethidine (meperidine) or other pain-killing/ tranquillising injections during labour. Why. A glucose or saline drip during labour. but it becomes credible when looked at in the light of the damage done by the side effects of drugs such as thalidomide.370 X INTRODUCTORY SOCIOLOGY G G G G G G G Vaginal examinations during labour. while others seek alternative treatment because of the perceived failings of orthodox medicine. G Iatrogenic illness Illness or disability caused by medical treatment. 24). Epidural analgesia during labour. produced a powerful critique of the effectiveness of medical treatments. Better drugs. Malpractice and negligence may be deﬁned as merely technical breakdowns in the system rather than ethically questionable behaviour by practitioners. Bladder catheterisation during labour. quite unexpected results appeared: ‘Possibly the most striking result [was the trial] in Bristol in which hospital treatment (including a variable time in a coronary care unit) was compared with treatment at home for acute ischaemic heart disease. Episiotomy. and make the impact of medicine one of the most rapidly spreading epidemics of our time’. that is. Cochrane (1971). Mechanical monitoring of contractions. QUESTION . impersonalised hospitals. In large. the dangerous contraceptive techniques devised for women and general malpractice. dysfunction. has alternative medicine become so popular? Use appropriate sociological concepts to construct your response. surgical techniques. Forceps or vacuum extraction of the baby. Mechanical monitoring of the foetal heart. p. It is important to recognise that the dominance of orthodox medicine in the formal health care sector does not encompass the whole of what Kleineman (1973) calls the cultural health system. pp. Despite the strength of orthodox medicine. The claimed efﬁcacy of scientiﬁc medicine is the second element of medicalisation. When the latter was done. While the evidence here is very persuasive. ‘the pain.
AM offers ‘a new consciousness of the value of involving the individual in her and his well-being and a new sense of being natural’. cancer.2 Despite their ‘alternative’ status. homeopathy. People are afraid of the iatrogenic effects of Western medical treatment (see above).H E A LT H . complementary therapies – like orthodox medicine – lay the emphasis of health care on the individual and tend to ignore wider social and environmental factors. acupuncture. According to Stanway (1982). the institutional entrenchment of orthodox health care is unlikely to be dismantled. chiropracture. there has been a steady rise in the popularity and availability of alternative treatments such as acupuncture. Despite this. natural versus synthetic. forcing the government to appoint junior ministers with responsibility for alternative medicine (AM). In a wider cultural context. Saks notes that there are ‘eighty-eight organisations in Britain covering seventeen or more alternative therapies’ (ibid. osteopathy. herbalism. Popular support for complementary medicine has led to political support in parliament. p. This is partly because of splits among AM practitioners in terms not only of what strategy to adopt professionally but also of how to describe their medicine. In broader terms. it must be good. organic versus chemical and holistic versus mechanistic. Some have religious/philosophical reservations about what is being offered by orthodox medicine. These differ in the extent to which they claim to offer a complete alternative to orthodox medicine or serve as a complement to it. AM practitioners face a number of dilemmas when orthodox doctors adopt aspects of their traditional medicine. there are ﬁve main reasons for the steady growth in the number of AM patients: G G G People believe that orthodox medicine is failing in certain ﬁelds. shiatsu and the Alexander technique. One reason for this is that orthodox practitioners may simply incorporate AM into their practice and turn a threat from competitors into an advantage for themselves. 16). If it is natural. health and nature’. Their response to AM tends to vary according to circumstances. for example. where doctors have the right to use whatever medical technique they regard as valuable when treating patients – prescription medicine. Some want to experiment with new medicine. This is especially true in Western Europe. . Although more and more patients may vote with their feet and seek treatment from AM practitioners. I L L N E S S A N D M E D I C I N E X 371 Since the early 1980s. Coward (1989) argues that the interest in AM is linked to a ‘new philosophy of the body. Incorporation usually involves the following: G G Figure 13. reﬂexology.. AM has yet to establish itself as an organised health care movement. and homeopathy makes much of this claim in its treatment. AM can be seen as part of a wider shift towards a naturalistic approach that contrasts lay versus expert. with another 17 000 non-registered practitioners. Saks (1992) estimates that in the UK about 11 000 therapists are registered with alternative medical associations. endoscopy and so on. this relates to the green movement and the ‘natural system’ idea of contemporary ecology. physiotherapy. Some want to protest about what is available in the orthodox system.
If it continues to expand. To the extent that AM achieves these goals – and its victories have been small and rather insigniﬁcant to date – it might be seen as another indication of the onset of postmodernism. with its challenge to rational scientiﬁc medicine. Hence. chronic inequality between various sectors of . Whatever the form of medicine delivered. In terms of one of the key themes of this book. as they lose their alternative identity (the very claim that makes them so attractive). but developments are likely to be orchestrated by orthodox researchers rather than AM practitioners themselves. many of the advances that AM groups have made have depended on professionalising themselves rather than on demonstrating the success of their treatment. cheap and patient-centred form of health care. for example. AM promotes the image of a natural. G G G The success of AM will depend as much on patient disaffection with orthodox medicine as on the capacity of AM lobbies to establish themselves in the medical system. radiographers (when practice first developed in 1920s). New research support may be provided. reminiscent of some of the fundamentalist beliefs of left-wing environmentalists. monitor members and prevent undesirables practising. chiropractors. However.372 X INTRODUCTORY SOCIOLOGY B O X 1 3 . AM practitioners gain access to a new medical market but they have to develop a working knowledge of orthodox medical terms to reassure new patients. mesmerism/neurohypnology (hypnosis). there is little evidence of AM posing a major threat to professional entrenchment. for example. In the UK. G Reject competitors completely. Inasmuch as it proposes a wide range of alternative therapies and distances itself from the authoritarianism of the professional elite. To secure a foothold in the health care system. shaky and ephemeral world of the postmodernist. professional bodies have been created to set standards. the knowledge it offers as an alternative is far removed from the unstable. for example. For example. many AM groups have adopted similar strategies to those utilised by early Western medical practitioners to establish their modernist credentials. AM is another illustration of the deconstruction of traditional forms of social authority (the medical profession) and conventional expertise (medical knowledge). osteopaths. for example. G G G Wider acceptance of AM by the public and the possibility of referral by GPs. one might wonder whether the AM movement. Competitors practise in subordinate position in law. the Council for Complementary and Alternative Medicine sets standards of AM care that mimic those of the General Medical Council. This poses a threat to the beliefs and therapies upon which AMs are based. Its popularity might reﬂect a wider desire to challenge powerful modernist practices and certainties. Recognition provides formal state blessing but on terms that require AM associations to police their members. holistic medicine that is grounded in a set of strong. overarching principles about nature and our place in it. it is likely to be through orthodox medical practitioners adopting it as a useful. As stated above. is part of a postmodernist critique of established medicine. a different view is that while AM challenges orthodox medicine. 3 Forms of control by orthodox practitioners over competitors G Incorporate on own terms competing ideas and skills. Competitors accept dominance of medical profession.
Good health promotes upward social mobility. In the 1970s. The argument here is that poor health has more to do with cultural practices and beliefs than material disadvantages. health inequality as cultural deprivation. TA B L E 1 3 . It is to this issue that we now turn. Poor nutrition. this position argues that poverty is a direct cause of ill-health. but that the independent variable is health itself. Therefore. artiﬁcially created as a result of the way in which data are gathered and analysed. 2 Chronic sickness rates by social class. 86). exhaustion from long working hours (especially on night shifts) and the general struggle to make ends meet make for poor health. In this explanation. 1994 (per cent) Socio-economic group Professional Unskilled Male 0–15 yrs 16 28 Male 65 and over 57 68 Female 0–15 yrs 11 8 Female 65 and over 53 65 Source: Office of Population Censuses and Surveys (1994. 26 years. One measure of this is high prescription rate for people living in poor inner-city areas. especially in the case of single pensioners and single-parent families. while 24 per cent of households (almost 12 million people) were on the margins of poverty. Here. mechanics. UK. health inequality as a process of social selection. whose chance of being in poverty has increased by 60 per cent. health differences are claimed to be a statistical ﬁction. occupation. There is no real causal relationship between class position and the quality of an individual’s health. Second. servants and labourers and their families. there is acceptance that health and class inequality are related. the prevalence of chronic sickness still varies according to social class. Millar (1993) relates this to high unemployment. Third. education. 1842). the average age of death was as follows: gentlemen and persons engaged in professions and their families. While these two groups reﬂect changing demographic patterns in society. the majority of those who are poor are so because they cannot secure work that will provide an adequate wage. as Table 13. inadequate hygiene facilities. They examined four explanations that have been offered to account for the statistical trends. tradesmen and their families. health inequality as an artefact. the growth of low-paid work and the increase in part-time casual labour.2 shows. The G G G . who argue that the most important factors affecting health are income. health is seen as a determinant of class position. a major survey of poverty in the UK (Townsend. especially among the very young and very old. p. Although the general standards of health have improved dramatically since then. 45 years. Fourth.H E A LT H . the ﬁgures have remained steady or worsened.3 million people) received an income that was lower than the Supplementary Beneﬁt level. Since Townsend’s study was published. while bad health results in downward mobility. G First. Against the second view. 16 years (Chadwick. The continuing inequality in morbidity and mortality across social classes has been explored in detail by Townsend and Davidson (1982). health inequality as material deprivation. X Health inequalities In Bethnal Green in 1839. I L L N E S S A N D M E D I C I N E X 373 the population in respect of general standards of health is likely to remain. housing and lifestyle. 1979) found that 7 per cent of households (3. The evidence suggests a direct relationship between these groups and high levels of illness and disease.
founded in July 1948.. such that more workingclass people die from smoking-related lung cancer than any other social group? It is argued here that certain social groups experience cultural deprivation throughout their lives in terms of knowing how best to manage their health needs. and. The . In the UK. it is those working in the National Health Service who have this responsibility. their ‘consumers’ (primarily their patients) and the state. the ‘Westernising’ East European (smoking Western cigarettes) or the Third World entrepreneur stocking the latest line in T-shirts promoting Camel cigarettes. alcohol consumption and diet. ethnic minority groups and the working class might be less likely to regard their illness as worthy of a doctor’s attention. the last two – the material and cultural accounts – are the favoured explanations of the patterns of morbidity and mortality. of course. as discussed in the next section. provide examples. be it by the newly assertive woman. X The contemporary health care system The principal health care system in the UK is national in scope and state-sponsored. their customers and their neighbours? If so. Smoking is clearly a social statement that brings pleasure as well as a chesty cough and lung cancer. a view not far removed from the ideas underlying the cultural deprivation approach. focus is on the relative cultural ability of social classes to use knowledge about health and the health services. Why do people smoke despite the evidence of its damaging effects? Why is the incidence of smoking higher among lower social classes. Tobacco companies. Smoking is one practice that might be used to illustrate this point. pages 72–82 and Chapter 5.374 X INTRODUCTORY SOCIOLOGY Cultural deprivation An approach that claims that lifestyle choices determine illhealth. in that medical professionals are the principal providers of health care (although there are high levels of self-healing). which provides the basic funding for the system while subjecting it to continual monitoring and evaluation. QUESTION What impact do industries such as the cigarette industry have on the general health of society? Do you think that all industries affect the health of their workers. The issues they raise are not simply the concern of academics and the medical profession: there is a strong governmental interest in using certain interpretations to support particular health policies. This is given greater momentum by the growing importance of health economics as an expert discipline – a highly modernist approach to the rationing of health care that provides ‘scientiﬁc’ grounds for deciding who should and who should not receive medical attention (Ashmore et al. is a medicalised health care system. It offers an explanation of the greater incidence of ill-health among working-class people by directly relating it to factors such as smoking. These four interpretations of the health statistics have been subject to sociological and medical debate for many years. The main actors involved are the various professionals. C O N N E C T I O N S Other disadvantages experienced by the lower social classes are outlined in Chapter 4. pages 110–18. rely on just this sort of association being made. A particularly attractive line for governments in periods of reduced state expenditure is that health should be seen as a matter of personal responsibility. The ultimate decision on treatment is taken by the managers and professionals working in state and private health care. Health services and insurance companies in advanced countries are penalising smokers because of this. in broad terms. In addition. 1989). Finally. The National Health Service (NHS). it is conceivable that smoking for the working class – and increasingly for women – is a symbol of deﬁance: a vehicle to assert their identity and personal control in social situations.
The NHS has a sort of ‘protected species’ status among the British public. In fee-paying systems. patients shop around for treatment. Privatisation of services within hospitals.H E A LT H . in practice it meant a shift from care in the community to care by the community. founding assumptions of the NHS were that expert. It is evident. then the BBC’s chief US political correspondent. life-threatening diseases and are offered the most advanced operations. describe the state of health care in the United States. The spiralling costs have caused many firms to set up a form of self-insurance for their workers’ health needs. albeit disguised by the rhetoric of efﬁciency and patient choice. It is also evident that private provision does not necessarily work more effectively than collective public provision. it has tended to be the primary vehicle for medical treatment for the bulk of the population. 4 Characterising the US health care system ‘Third world medicine at superpower prices’ – in such terms did Gavin Esler. scientiﬁc medicine was good in itself and had collective approval. This view of a system that mixes deprivation with excess is shared by many commentators on the US. The US spends more than any other country on its health care – about 14 per cent of GDP. while insurance companies are under attack from firms whose duty to provide private sickness benefit for employees has forced up the cost of insurance and eroded corporate profits. and that primary care should be provided by doctors and hospitals. As the NHS has traditionally provided free health care. US citizens have access to very expensive treatment for rare. Yet over 30 million out of the 250 million US citizens have no health care provision whatsoever – public or private. for example. and any governmental threat to its existence is regarded as political suicide. the medical market is more competitive. but there are no mass vaccination programmes to provide cheap preventative medicine at $3 a shot. thus removing the costly third party – the insurance company – from the scene. This is partly because it is free at the point of delivery: no one wants to pay for treatment. that major economic interests – not always convergent with each other – are tied into the US health care system. Yet the NHS is still under government attack. During the 1980s and early 1990s. Marketisation: the promotion of patient choice and the introduction of fund-holding for doctors. That so massive an expenditure is failing to provide basic health for millions poses a social and a political problem for the US government. G G . the insurance sector and the pharmaceutical industry. is being pressed to reduce the price of drugs because the profit margins are excessive. The latter. and. The policy problem is to reduce the bill while improving the provision of health care. it has nevertheless been a powerful myth that both professionals and consumers have helped to reproduce over the years. a number of crucial changes were made to the operation of the NHS that affected its essential character: G Community care: while this was claimed to be a progressive policy promoting de-institutionalisation. I L L N E S S A N D M E D I C I N E X 375 B O X 1 3 . and litigation is common. and is therefore transparent. but far less so in developing countries. But it is also because of a well-rooted belief that health care is safer when it is not commercialised. While this belief may rest on an oversentimental attachment to something that has never lived up to its image. accountable and reliable. as a result. The political problem is that achieving this will require a stateled attack on the powerful institutions that benefit from the system: the medical and legal professions. This set of assumptions is found in most industrialised countries. then. more than twice that spent in the UK.
. Moreover. and one that was not necessarily coherent: for example. these developments resulted in a qualitative change to the NHS. Who decides what needs are. an increase in health charges (for example. Ideology: a shift in emphasis from public health care to private health care. the introduction of self-governing trust hospitals. health care needs were redeﬁned and placed within more restricted boundaries. One criticism of PFI is that it will only work for projects that serve the interests of private corporations. while social needs such as respite care and community care were made the responsibility of social services and/or the family. private and charitable hospitals and health services). and to tackle health inequality by reducing inequality in general. the government abolished fund-holding by general practices but set up new commissioning authorities. based on the dictates of supply and demand. and that this will distort planning for the health care needs of patients. but many commentators argued that it would lead to additional administration costs and a two-tier system in which some people would receive an inferior service.) In practice. Under New Labour. but there was still a separation between those who purchased health care on behalf of patients and those who provided care. The idea was to create efﬁciency-generating competition between providers. for prescriptions and dental care). (It had long been recognised that people in countries with lower overall levels of inequality. an example of which is the construction of a new general hospital in Norwich by a private company that will lease it to the NHS upon completion. enjoyed better than average health and a lower mortality rate. There was also a de-medicalisation of health care – especially for the elderly – in that social services were expected to take on more responsibility for the sick. which meant that the two-tier system of health care within the NHS was eliminated. such as Sweden and Japan. G De-medicalisation The process whereby orthodox medicine loses its ability to define and regulate areas of human life (see medicalisation). however. Marketisation An economic concept that describes the process of exchange and the distribution of services and goods by private individuals or corporate bodies. The marketisation and privatisation of the NHS under consecutive Conservative governments was based on the separation of those who purchased health care (fundholding doctors and local health authorities) – the famous purchase/provider divide – from those who provided health care (public. and there remained an element of this in the new system. Commentators are divided over whether this amounts to the creeping privatisation of NHS care or represents a sensible ‘mixed economy’ of provision. the broader issue of health inequality. PFI is based on a partnership between the public and the private sectors. The above developments conﬁrm that the deﬁnition and satisfaction of health needs are as much political as medical matters. The increasing use of vacant private sector beds for NHS patients is portrayed as a means of meeting the demand for NHS care without having to build new NHS hospitals or enlarge existing ones. Together. The New Labour government elected in 1997 pledged to abolish the purchaser/ provider divide. one of the main reasons for the establishment of the NHS. community care seemed to work against patient choice by denying any real alternative to domiciliary care. especially when the health care system is ostensibly based on an equitable distribution of resources provided free of charge. links have been established between the public and private health care sectors through the private ﬁnance initiative (PFI) and the increased use of private sector beds for NHS patients. was neglected in favour of cost reduction and the efﬁcient use of resources. For example. New Labour policies showed continuities as well as breaks with previous policies. The health care model adopted by the previous Conservative administration had been designed to operate on market principles. with the individual being responsible for her or his own well-being.376 X INTRODUCTORY SOCIOLOGY G Resource costs: stress on new managerialism and health economics. At the same time. how they should be met and at what level are questions for political debate. to base health care on partnership rather than competition.
the more similar the global patterns of health and illness. in which the provision of public health care resources has to be accompanied by responsible (healthy) citizenship. The more the world economies are integrated in terms of production and consumption. It argued that the main health problems of the twentieth century were due to personal health behaviours. The rise in the level of state support for national medical provision is a problem shared by many advanced industrial states. and the more the culture of the West (notably in its American form) comes to predominate. notably Sklair’s (1991) transnational classes. C O N N E C T I O N S The general impact of globalisation is discussed in Chapter 3 – see pages 54–64 in particular. while countries such as France. X The globalisation of health. Managerialism A process of increased managerial control. illness and medicine In Chapter 4. More generally. and. . and access to health care will become. Finally. Solutions to the problem involve a mixture of increased managerialism. The risks to health were conceptualised as predominantly those associated with individual behaviours and lifestyles – especially the holy trinity of risks: smoking. I L L N E S S A N D M E D I C I N E X 377 B O X 1 3 . the government finally acknowledged that it had responsibilities for the health of the population that went beyond the provision of a health-care system. 156–7). and reﬂects the individualistic. taking exercise and eating a healthy diet. potentially victim-blaming focus that has long been a tradition in UK health policy (see Box 13. Klein (1995) has argued that . 5 Health policies and individual risk In ‘The New Politics of the NHS’. This resurrects the old preoccupation with giving up smoking. People are expected to adopt healthy practices and abandon those which pose a risk to their health. Germany and Sweden spend 8–9 per cent.. New Labour has intimated that spending on health care in the UK will rise to European levels. Source: Nettleton and Burrows (1998. It should come as no surprise that patterns of morbidity and mortality also have a globalised dimension.. A further aspect of New Labour policy is the idea of a partnership in prevention. a tendency to rely on carers in the community – a responsibility that falls most heavily on women. we saw how the contemporary world can be regarded as a global system. In its early days in ofﬁce. (The UK currently spends around 6 per cent of its GDP on health care. pp. in the 1990s (we have) ‘a new health policy paradigm’. In short. an emphasis on health care via the market. The ‘Health of the Nation’ White Paper and subsequent documentation set out the government’s strategy to improve the nation’s health. despite the growth in the bureaucracy that oversees medicine. however. shaped by major cultural and economic players. this is dependent on the continued growth and prosperity of the UK economy.5). exercise and diet. the more similar the international structures of class inequality will become.) However. Within the health literature there appears to be an emerging consensus that health and medicine work within a new framework or paradigm – one which is governed by notions of surveillance and risk. the government’s approach to prevention has been couched in terms of Tony Blair’s ‘third way’. good and poor nutrition. drinking sensibly.H E A LT H . the government identiﬁed a number of ‘health action zones’ where high levels of material disadvantage needed to be addressed in order to improve the health of the inhabitants.
medicine is playing an important scientiﬁcally and professionally grounded role as a regulator of individual and collective bodies in all societies. From practitioners’ perspectives. alongside alternative medicine there are lay remedies for coping with illness – such as ‘feed a cold and starve a fever’ – and prescriptions for remaining healthy. The GATT (General Agreement on Tariffs and Trade) agreement encouraged this by ensuring that the proprietary rights of drug companies were observed in a wider range of countries. In addition. at both the micro and the macro level of analysis. In the ﬁeld of medical research. in China. the communication and information technologies that are crucial to the globalisation process are playing a growing role in medical science and medical practice. It should be clear that the role of the medical profession involves more than curing sickness. indigenous or traditional forms of medicine in Africa. the social basis of health and illness is evident. It also shapes the deﬁnitions of health and illness and is closely tied to major economic and political interests. However. therefore. as a feature of modernity common to all industrialised states. Similarly. Because the major drugs companies are merging to become truly global ﬁrms – such as SmithKline Beecham and Glaxo-Wellcome – the drugs they develop are geared to global markets. access to international databases is important for keeping up with new developments and exchanging information quickly in standardised formats. strokes and heart disease predominating whatever the national context. there has been a globalisation of the institutional responses to the demand for health care. the globalisation process has prompted resistance at the local level. The globalisation of common forms of medical practice and their associated technologies – such as scanning devices. illness and medicine is built. ‘rational’ systems of medical delivery that go beyond national boundaries. Moreover. highly bureaucratic. the global patterns of morbidity and mortality are converging. this was openly advocated by the government until recently. Asia and the Paciﬁc Rim countries are still popular and are often practised alongside modern medicine: indeed. as in the Human Genome Project. that is. Even in Western societies. transnational pharmaceutical companies have had their global dominance checked by small competitor companies in Southern states that are keen to cut their health care bills. Major suppliers of equipment. the paraphernalia of intensive care units and so on – reﬂects the existence of an international network of medical practitioners who share similar requirements and standards. For example. it also opens up intriguing questions about doctor– patient relations and the continuing relevance of the bed-side manner! At the same time. Sociologically. . the digitalisation of patients’ records allows doctors to discuss cases over the Internet without meeting the patient. drugs and other medical items are under pressure to pursue the same technical innovations in order to remain competitive. such as ‘don’t go out with your hair wet’. It also reﬂects the way in which modernity has encouraged the standardisation of technologies and instruments (not only in medicine but also elsewhere). Not only does this encourage greater international standardisation of symptomatology and diagnosis. thus securing and stabilising world markets for them.378 X INTRODUCTORY SOCIOLOGY According to Turner (1987). Finally. while conforming to quality standards set by international regulatory agencies. It is doubtful whether either of these are global injunctions! X Conclusion This chapter has explored the theoretical and empirical basis upon which the sociology of health. with cancer. its curative and healing powers are often less effective than its modernist self-image would have us believe.
for example – in the way this power is expressed and in its historical origins. There are five main theoretical approaches to health. would you look to the US or UK model for your inspiration? Justify your answer. feminist and Foucauldian approaches. the social and the societal. Health inequalities reflect wider social divisions. drugs and equipment. disability and the body. with chapters on medical knowledge and lay beliefs about health. . Nettleton. although there are differences – between the UK and US. Try the chapters on ‘the disabled body’ and ‘the body in pain’ as a starting point.H E A LT H . I L L N E S S A N D M E D I C I N E X 379 X Chapter summary G G G G G G G G G Sociology challenges the biomedical model of health and illness by demonstrating the social bases of both. Given the existence of health inequalities. the relationship between the public and the medical profession. The medical profession has established itself as the principal authority in the medical market. Mary and Ellie Lee (eds) (2002) Real Bodies: A Sociological Introduction. Palgrave. Marxist. Turner (1992) has developed a valuable model that attempts to integrate these approaches by analysing at the level of the individual. although its full privatisation seems unlikely. However. Alternative medicine challenges orthodox medicine but cannot be seen as a postmodern critique. The NHS. X Investigating further Doyal. Some of the chapters in this collection are more demanding than others but they include some interesting discussion of how much our bodies are ‘real’ or ‘constructed’. Evans. and why? If you had the power to construct a medical system for the twentieth century. Palgrave. Polity Press. in terms not only of patterns of morbidity and mortality but also the convergence of forms of treatment. interactionist. should more resources be targeted at the chronically ill? Produce an argument for both sides of this question. health inequalities. local resistance to this convergence is apparent. like state-sponsored health care elsewhere. Sarah (1995) The Sociology of Health and Illness. A good. although there are a number of possible interpretations of the health statistics used to back this assertion. Lesley (1995) What Makes Women Sick: Gender and the Political Economy of Health. clear overview text. scientific medicine is associated with the growth of professional medical expertise and state-sponsored institutions of health care. illness and medicine: the functionalist. X Questions to think about G G G Which of the ﬁve theoretical models of health and illness do you ﬁnd most convincing. is undergoing fundamental change. Health has global dimensions. This book offers a useful critique of the medical model. focusing on global patterns of health and disease among women. The development of rational. both of which exemplify the impact of modernity on the health care system.