STOW COLLEGE

MANAGEMENT AND GENERAL EDUCATION DEPARTMENT

 

HEALTH

 

MEDICAL AND SOCIAL MODELS OF HEALTH

 

 

The medical model of health is based on knowledge about the physical and biological causes of disease.  It sees health as the absence of disease.  It developed with the growth of the medical profession and tends to take a curative approach.  Doctors tend to favour this model.

 

Sociologists favour the social model of health, which focuses on the social distribution of health and illness between different groups (eg death rates vary between social classes).  The social model is interested in the environmental and social causes of ill health.  It tends to take a preventive approach.  In recent years, doctors have begun to acknowledge the importance of social influences on health, such as stress factors and lifestyle, and it is now recognised that good health is more than merely an absence of disease.  The World Health Organisation defines it as ‘a state of complete physical, mental and social wellbeing’.

 

Sociologists are interested both in how health and illness are socially caused and in how they are socially caused and in how they are socially constructed.  An example of the social constructed.  An example of the social causes of ill health is poor living conditions, while an example of the social construction of health is that different cultures have different ideas about what it means to be healthy or ill.

 

Sociologists use the term illness to describe the individual’s subjective experience of ‘feeling unwell’ .   The term sickness refers to a social status which is defined professionally, for instance, by a doctor who issues a sick note, while disease is a term to describe a biological malfunction.

 

 

Class inequalities in health and health care

 

‘Health chances’ refers to a person’s chances of enjoying good health and long life (or suffering poor health and dying early).  There are two main measures of health chances: mortality statistics (which measure death rates) and morbidity statistics (which measure rates of illness).  Mortality statistics are more reliable than morbidity statistics because deaths can be counted more accurately than illness.

 

Studies provide evidence that health chances are unequally distributed.  The Black Report (1980) showed that, despite the introduction of the NHS and an improvement in living standards over the previous 30 years, a steep class gradient in health remained.  At all ages, lower social classes (measured by occupation) experience higher mortality rates for almost all causes of death.  Recent evidence shows that the health gap between the classes has widened since 1980.

 

Professional, man, tech (women)

Skilled non-man

Skilled manual

Partly & unskilled

Professional, man, tech  (Men)

Skilled non-man

Skilled manual

Partly & unskilled

 
 
 


The Black Report offers four explanations of class inequalities in health:

 

q       The social selection explanation This is the view that illness is not the result of low income and poverty, but the cause of them.  Healthy people are more likely to be upwardly mobile, while those who are ill become downwardly mobile, eg because they missed out on school through illness.

 

q       The artefact explanation This view states that statistical comparisons between social classes tend to exaggerate the extent of inequality because the working class (the poor health class) is shrinking while the middle class (the good health class) is expanding.

 

q       Cultural and behavioural explanations.  Unequal health stems from differences in the behaviour of people from different classes: working class people have worse health because they are more likely to engage in health-damaging behaviour, such as smoking, drinking alcohol, etc.  Some argue that behavioural differences between the classes result from cultural differences, however, Marmot shows that only a small part of the class gap in mortality is due to health-damaging behaviour.

 

q       Structural and material explanations.  These see social inequality and material conditions as the cause of health inequalities.  These include poverty and material deprivation stemming from unemployment, low income, bad housing conditions, polluted environments, and unhealthy or dangerous working conditions.  Low social position is associated with a lack of control over one’s life and with higher levels of stress and thus poor health.

 

The Black Report suggested that the cultural/behavioural and structural/material explanations are the most valid.

 

Graham argues that cultural explanations ‘blame the victim’ and that people engage in health-damaging behaviour like smoking because of structural factors such as poverty. She found that women in poor households smoked as a way to cope with stress.

 

Statistics show that the working class suffer worse health that the middle class.  Do they therefore make more or better use of health care than the middle class?  According to Tudor-Hart, there is an ‘inverse care law’: the groups with the worst health (such as the working class) get the least access to health care resources, and the middle class benefit from health services.

 

Cartwright’s studies of the doctor-patient relationship illustrate this.  She shows that although the working class make more use of health services (eg they visit GPs more often), the middle class get more from the system.  Middle class patients have longer consultations and ask for and get more information from doctors.  They are also more likely to get a second opinion, be referred to a consultant, gain admission to specialist hospitals, and make use of preventative and screening services.

 

Similarly, Le Grand shows that although the working class have poorer health, they receive proportionally less from the health service than the middle class.  He estimates that when need is taken into account, class I receives over 40 per cent more health care from the NHS than class V.  This is because although the NHS is free of charge, it is more costly for lower income groups to use it.

 

 

GENDER DIFFERENCES IN HEALTH AND HEALTH CARE

 

Women live longer than men but they report more illness.  However, because they live longer than men, women are more likely to suffer from chronic diseases.  This partly explains why two-thirds of the disabled population are women.

 

There are four main explanations of gender differences in health and health care:

 

q       Biological Cross-cultural evidence indicates that gender differences in mortality are largely biological in origin: women live longer than men in most societies.  However, social factors do influence mortality rates.  For example, women’s life expectancy improved more than men’s during the 20th century because of a dramatic decline in deaths in childbirth.

 

q       Artefact In this view, higher morbidity rates for women could simply reflect a greater willingness or opportunity to seek help when they have symptoms of illness, and not greater sickness.

 

q       Cultural There are two views about the influence of culture: the ‘licence’ view, which suggests it is more acceptable for women to admit being ill, and the ‘women coping’ view, which suggests that women are expected to cope with being ill because of their domestic responsibilities.

 

q       Structural and material  Women spend more time at home, which means that bad housing is likely to affect them more.  Women are also more likely to suffer poverty, eg as lone parents.  Bernard shows are married women (and single men) have the worst health, including mental health, because married women sacrifice their own well-being for their husbands and families.

 

Most health care is provided by women:

 

q       Informal care in the home, looking after sick children or elderly relatives, is generally seen as part of women’s gender role.

 

q       Formal care by paid workers is largely women’s work too: most NHS employees are female.

 

 

ETHNIC DIFFERENCES IN HEALTH AND HEALTH CARE

 

Some illnesses and conditions correlate with ethnic background.  For example, those born on the Indian sub-continent have above average rates of heart disease, diabetes and tuberculosis but lower rates of cancer and bronchitis, while those born in Africa or the Caribbean have above average rates of stroke, high blood pressure and diabetes.

 

However, there are problems in comparing the health of different ethnic groups because ethnic categories are difficult to define, and because the health chances of an ethnic group tend to reflect its class position.

 

There are three main explanations of ethnic differences in health:

 

q       Genetic There are links between certain genetic disorders and ethnic origin.  For example, sickle cell disease is much more common among people of African ancestry.  However, genetic differences between ethnic groups account for only a tiny proportion of all illnesses.

 

q       Cultural These explanations focus on the cultural norms, values and lifestyles of ethnic groups.  For example, heart disease among Asians has been blamed on the use of cooking fats.  However, Nettleton criticises explanations that blame minorities for health damaging behaviour but overlook their healthy practices, such as low consumption of alcohol and tobacco, especially by Asian women.

 

q       Structural and material  Some ethnic minorities – notably Afro-Caribbeans, Pakistanis and Bangladeshis – experience high rates of unemployment, low pay, poor housing and limited educational opportunities.  From this point of view, the poorer health of some ethnic groups is not caused by genetic or cultural factors but reflects their class position and the effects of discrimination.

 

Studies of the take-up of health care by ethnic minorities, such as Rudat’s, suggest that problems of communication may result in minorities receiving poor quality care, including less effective consultations and below-average use of preventative services.  Translation services are poor and health care staff are often unable to respond to the language needs of ethnic minority patients.  Some argue that such barriers to access are a result of institutional racism in the NHS.

 

MEDICINE AND THE MEDICAL PROFESSION

 

Sociologists are interested in the impact and role of medicine and the medical profession in society.  The general health of the population has clearly improved (eg during the 20th century, life expectancy almost doubled), but is this due to medicine and doctors?

 

Studies show that medical care and medical discoveries have often had relatively little influence on health compared with social factors.

 

McKeown’s historical evidence suggests that medical care had relatively little effect on death rates before the 20th century.  Most deaths were from infectious diseases (TB, cholera, measles, etc), and the biggest improvements in health were brought about by public health measures such as improved sanitation, clean drinking water, and better housing, diet and a higher standard of living.

 

Illich goes further, arguing that modern high-tech curative medicine and the medical profession are a danger to our physical, mental and spiritual health.  He uses the term iatrongenic illness – those caused by medical intervention – to describe this danger, such as the side effects of drugs, errors by doctors, etc.  There has been a ‘medicalisation of life’ and we have lost control over own bodies, lives, suffering and death and become dependent on the medical profession, the ‘new priesthood’.

 

If medicine and the medical profession are not responsible for improvements in public health, what is their function?  Different perspectives give different answers.

 

q       Functionalists such as Parsons argue that being sick has potentially disruptive effects on society.  Sickness is a form of deviance that needs to be controlled.  Otherwise, the behaviour associated with it, such as dependency, apathy and incapacity, could become widespread and threaten the smooth functioning of society.  It is therefore important to restrict access to the sick role to those who are genuinely sick.  This is the function of the doctor, whose authority is maintained by his or her objective scientific knowledge and high status.

 

The sick role involves both rights and obligations: the right to be exempted from normal role obligations (such as work) and to be looked after, and the obligation to want to get better, to seek help and to obey doctor’s orders.

 

Access to the sick role has to be legitimised by the medical profession.  Failure to comply with its obligations may result in society withdrawing from the individual the right to be considered sick and/or imposing sanctions.  The function of the medical profession is one of social control: it polices the sick role, ensuring that only the genuinely sick gain access to it.

 

Parsons recognises that medicine and sickness have social as well as biological dimensions.  However, he assumes that medicine is a ‘good thing’ and that the medical profession works for the interest of society.  His explanation also fits short-term, curable illnesses better than long-term, chronic illnesses.

 

q       Conflict perspectives include Weberian, Marxist and feminist approaches.  They see the role of the medical profession differently.  All of them see it as benefiting some special interest group rather than society as a whole.

 

q       Weberians such as Freidson see doctors as self-serving and using their monopoly of medical knowledge to preserve their own power and status.

 

q       For Marxists, medicine and the medical profession perform important functions for capitalism, but not for society as a whole.  Doctors act as agents of social control, ensuring that an alienated workforce cannot escape to the sick role but remains at work to produce profits.  They reproduce the workforce by ‘patching up’ sick workers.  Ideologically, they mask the exploitation of capitalist society, making it appear more caring.  Medicine and health care also enormous sources of profit for giant multinational drugs companies.

 

q       Feminists see society as patriarchal and doctors as perpetuating this.  Medicine has a social control function, ensuring that women are kept in a subordinate role, for example by controlling women’s fertility (eg through the medicalisation of pregnancy and childbirth, and control over access to abortion and contraception).  Doyal describes how doctors often stereotype women as emotional, neurotic, less objective and more excitable than men.  Even when there is clear evidence that a woman’s problem is physical, doctors often see it as having a psychological cause.

 

THE SOCIAL CONSTRUCTION OF HEALTH, ILLNESS AND DISABILITY

 

Health, illness and disability can all be seen as socially defined or constructed.  That is, they are created by the labels, definitions or meetings that we attach to ourselves and others, and by the way we act upon these meanings. One example of social construction is mental illness, which is covered in the next section.  Here we shall look at physical illness and disability.

 

Interactionists are interested in how individuals come to acquire illness labels, and the effects these labels have on them and those around them.  They are interested in how doctor-patient interactions create such labels.

 

But how do people decide they are ‘ill enough’ to go to the doctor in the first place?  Zola argues that friends and relatives are often important in interpreting something as a ‘symptom’ worthy of the doctor’s attention.  He also argues that patients’ reasons for seeking medical help are affected by cultural background.  His study in the USA found that Italians often sought help because symptoms interfered with personal relationships.  Anglo-Saxons were more likely to seek help if symptoms affected their work, while the Irish were likely to present symptoms because of pressure from others to seek help.

 

Interactionists are interested in how doctors and patients negotiate a diagnosis (ie a sickness label).  Byrne and Long found that there is a conflict between doctors’ and patients’ views of the ideal consultation (not surprisingly, doctors prefer short, doctor-centred consultations).

 

Doctors generally have more power in these interactions, but patients are not always passive and may try to create their own diagnosis and get the doctor to agree to it.

 

While the medical model equates disability with illness, sociologists generally see disability as socially constructed.  We can distinguish between impairment, which involves loss of physical, sensory or intellectual functioning, for example, being partially sighted or lacking a limb, and disability, which refers to the restrictions society places on people who have impairments.

 

Using this distinction, Shakespeare argues that disability is a social and not a medical problem, stemming from society’s failure to address the needs of people with impairments.  In this view, disability is the result of discrimination.  Social and environmental barriers exclude people with impairments from participation in mainstream society.  Society has disabling effects when its buildings, education, employment and transport systems fail to meet the needs of people with impairments.

 

Impairment may have social causes.  For example, accidents at work, poor quality housing, etc can cause injury and disease.  In general manual workers and their families are at greater risk of impairment.

 

MENTAL ILLNESS

 

There are two main sociological approaches to the study of mental illness: the positivist approach and the interactionist approach.

 

q       The positivist approach tends to accept medical definitions and assumes that mental illness is an objective ‘thing’ or disease.  This approach examines the distribution of mental illness among different groups in society and seeks to discover its causes.

 

For example, Hollingshead and Redlich show that members of class V were over six times more likely than members of class 1 suffer from mental illness.  Faris and Dunham found rates of mental illness were highest in areas of Chicago that had high levels of social disorganisation.  This approach traces mental illness to the way society is organised and the position of the individual in the social structure.

 

Feminists argue that the higher rates of mental illness among women are caused by their position in the social structure, for example, as a result of the stress factors associated with their domestic roles.  Similarly, racial discrimination and disadvantage faced by ethnic minorities create stress and may result in higher rates of mental illness.

 

q       The interactionist approach sees mental illness not as a disease or medical condition, but as a social construct: a label or social status conferred on some individuals by others (eg psychiatrists) who have the power to do so.  Interactionists focus on the labelling process when someone is defined as mentally ill.  For example, in Rosenham’s pseudo-patient experiment, the researchers gained admission to mental hospitals by claiming (falsely) to hear voices.  Once admitted, they found that staff interpreted all their behaviour as symptoms of mental illness.

 

Such labelling can create a self-fulfilling prophecy: once defined and treated as ‘mentally ill’, a person may begin to see themselves, and act, as mentally ill.  Goffman describes how an individual’s identity changes once admitted to a total institution such as a mental hospital.  On admission, the individual’s old identity is destroyed, and they are given the new identity of ‘inmate’.  Similarly, Lemert describes how labelling a person as paranoid creates a vicious circle where other people begin to avoid them; this isolates the person, increasing their paranoia.

 

q       Szasz argues that mental illness is not really illness at all, but a label attached to individuals whose behaviour does not conform.  In his view, psychiatry is a form of social control.  Scheff sees differences in status and power as central to this labelling process: those who have least power are most likely to be labelled as mentally ill.

 

q       Women are more likely than men to be admitted to a mental hospital for almost all the major mental illnesses.  This is partly because women are more likely to admit distress and define their problems in mental health terms.  However, feminists argue that doctors tend to see female patients as hysterical and interpret women’s physical symptoms as having psychological causes.

 

Pilgram and Rogers describe how social judgements about deviance are influenced by gender stereotypes.  Women are stereotyped as vulnerable and passive, so that when they are deviant (eg behaving aggressively), this is more likely to be seen as irrational and needing psychiatric treatment.  Men’s deviance is more likely to be seen as intentional and dangerous, and so they are more likely to be seen as intentional and dangerous, and so they are more likely to be regarded as criminal than mentally ill.

 

Pilgram and Rogers see stereotyping as the reason for the higher rate of mental illness among Afro-Caribbeans, especially young men.  They are much more likely than their white counterparts to be labelled as dangerous by the police and courts and referred much more frequently for psychiatric assessments.