Understanding Health, Medicine, and Society

LEARNING OBJECTIVES:

1. Understand the basic views of the sociological approach to health and medicine.
2. List the assumptions of the functionalist, conflict, and symbolic interactionist perspectives on health and
medicine.

Health refers to the extent of a person’s physical, mental, and social well-being. This definition, taken from the World
Health Organization’s treatment of health, emphasizes that health is a complex concept that involves not just the
soundness of a person’s body but also the state of a person’s mind and the quality of the social environment in which she
or he lives. The quality of the social environment in turn can affect a person’s physical and mental health, underscoring
the importance of social factors for these twin aspects of our overall well-being.
Medicine is the social institution that seeks both to prevent, diagnose, and treat illness and to promote health as just
defined. Dissatisfaction with the medical establishment has been growing. Part of this dissatisfaction stems from soaring
health-care costs and what many perceive as insensitive stinginess by the health insurance industry, as the 2009 battle
over health-care reform illustrated. Some of the dissatisfaction also reflects a growing view that the social and even
spiritual realms of human existence play a key role in health and illness. This view has fueled renewed interest in
alternative medicine. We return later to these many issues for the social institution of medicine.

The Sociological Approach to Health and Medicine

We usually think of health, illness, and medicine in individual terms. When a person becomes ill, we view the illness as a
medical problem with biological causes, and a physician treats the individual accordingly. A sociological approach takes a
different view. Unlike physicians, sociologists and other public health scholars do not try to understand why any one
person becomes ill. Instead, they typically examine rates of illness to explain why people from certain social backgrounds
are more likely than those from others to become sick. Here, as we will see, our social location in society—our social class,
race and ethnicity, and gender—makes a critical difference.

A sociological approach emphasizes that our social class, race and ethnicity, and gender, among other aspects of our social backgrounds, influence our
levels of health and illness.

U.S. Army Garrison Japan – Arnn students celebrate diversity; weeklong recognition – CC BY-NC-ND 2.0.

The fact that our social backgrounds affect our health may be difficult for many of us to accept. We all know someone, and
often someone we love, who has died from a serious illness or currently suffers from one. There is always a “medical”
cause of this person’s illness, and physicians do their best to try to cure it and prevent it from recurring. Sometimes they
succeed; sometimes they fail. Whether someone suffers a serious illness is often simply a matter of bad luck or bad genes:
we can do everything right and still become ill. In saying that our social backgrounds affect our health, sociologists do not
deny any of these possibilities. They simply remind us that our social backgrounds also play an important role
(Cockerham, 2009).

A sociological approach also emphasizes that a society’s culture shapes its understanding of health and illness and practice
of medicine. In particular, culture shapes a society’s perceptions of what it means to be healthy or ill, the reasons to which
it attributes illness, and the ways in which it tries to keep its members healthy and to cure those who are sick (Hahn &
Inborn, 2009). Knowing about a society’s culture, then, helps us to understand how it perceives health and healing. By the
same token, knowing about a society’s health and medicine helps us to understand important aspects of its culture.

An interesting example of culture in this regard is seen in Japan’s aversion to organ transplants, which are much less
common in that nation than in other wealthy nations. Japanese families dislike disfiguring the bodies of the dead, even for
autopsies, which are also much less common in Japan than other nations. This cultural view often prompts them to refuse
permission for organ transplants when a family member dies, and it leads many Japanese to refuse to designate
themselves as potential organ donors (Sehata & Kimura, 2009; Shinzo, 2004).

As culture changes over time, it is also true that perceptions of health and medicine may also change. Recall from Chapter
2 “Eye on Society: Doing Sociological Research” that physicians in top medical schools a century ago advised women not
to go to college because the stress of higher education would disrupt their menstrual cycles (Ehrenreich & English, 2005).
This nonsensical advice reflected the sexism of the times, and we no longer accept it now, but it also shows that what it
means to be healthy or ill can change as a society’s culture changes.

A society’s culture matters in these various ways, but so does its social structure, in particular its level of economic
development and extent of government involvement in health-care delivery. As we will see, poor societies have much
worse health than richer societies. At the same time, richer societies have certain health risks and health problems, such as
pollution and liver disease (brought on by high alcohol use), that poor societies avoid. The degree of government
involvement in health-care delivery also matters: as we will also see, the United States lags behind many Western
European nations in several health indicators, in part because the latter nations provide much more national health care
than does the United States. Although illness is often a matter of bad luck or bad genes, the society we live in can
nonetheless affect our chances of becoming and staying ill.

Sociological Perspectives on Health and Medicine

The major sociological perspectives on health and medicine all recognize these points but offer different ways of
understanding health and medicine that fall into the functional, conflict, and symbolic interactionist approaches. Together
they provide us with a more comprehensive understanding of health, medicine, and society than any one approach can do
by itself (Cockerham, 2009). Table 18.1 “Theory Snapshot” summarizes what they say.

Table 18.1 Theory Snapshot

Theoretical
perspective Major assumptions

Good health and effective medical care are essential for the smooth functioning of society. Patients must perform the “sick role” in
Functionalism order to be perceived as legitimately ill and to be exempt from their normal obligations. The physician-patient relationship is
hierarchical: the physician provides instructions, and the patient needs to follow them.

Social inequality characterizes the quality of health and the quality of health care. People from disadvantaged social backgrounds
Conflict theory are more likely to become ill and to receive inadequate health care. Partly to increase their incomes, physicians have tried to
control the practice of medicine and to define social problems as medical problems.

Health and illness are social constructions: Physical and mental conditions have little or no objective reality but instead are
Symbolic
considered healthy or ill conditions only if they are defined as such by a society. Physicians “manage the situation” to display their
interactionism
authority and medical knowledge.

The Functionalist Approach

As conceived by Talcott Parsons (1951), the functionalist perspective on health and medicine emphasizes that good health
and effective medical care are essential for a society’s ability to function. Ill health impairs our ability to perform our roles
in society, and if too many people are unhealthy, society’s functioning and stability suffer. This was especially true for
premature death, said Parsons, because it prevents individuals from fully carrying out all their social roles and thus
represents a “poor return” to society for the various costs of pregnancy, birth, child care, and socialization of the individual
who ends up dying early. Poor medical care is likewise dysfunctional for society, as people who are ill face greater difficulty
in becoming healthy and people who are healthy are more likely to become ill.

For a person to be considered legitimately sick, said Parsons, several expectations must be met. He referred to these
expectations as the sick role. First, sick people should not be perceived as having caused their own health problem. If we
eat high-fat food, become obese, and have a heart attack, we evoke less sympathy than if we had practiced good nutrition
and maintained a proper weight. If someone is driving drunk and smashes into a tree, there is much less sympathy than if
the driver had been sober and skidded off the road in icy weather.
Second, sick people must want to get well. If they do not want to get well or, worse yet, are perceived as faking their
illness or malingering after becoming healthier, they are no longer considered legitimately ill by the people who know
them or, more generally, by society itself.

Third, sick people are expected to have their illness confirmed by a physician or other health-care professional and to
follow the professional’s advice and instructions in order to become well. If a sick person fails to do so, she or he again
loses the right to perform the sick role.

If all of these expectations are met, said Parsons, sick people are treated as sick by their family, their friends, and other
people they know, and they become exempt from their normal obligations to all these people. Sometimes they are even
told to stay in bed when they want to remain active.

Physicians also have a role to perform, said Parsons. First and foremost, they have to diagnose the person’s illness, decide
how to treat it, and help the person become well. To do so, they need the cooperation of the patient, who must answer the
physician’s questions accurately and follow the physician’s instructions. Parsons thus viewed the physician-patient
relationship as hierarchical: the physician gives the orders (or, more accurately, provides advice and instructions), and the
patient follows them.

Parsons was certainly right in emphasizing the importance of individuals’ good health for society’s health, but his
perspective has been criticized for several reasons. First, his idea of the sick role applies more to acute (short-term) illness
than to chronic (long-term) illness. Although much of his discussion implies a person temporarily enters a sick role and
leaves it soon after following adequate medical care, people with chronic illnesses can be locked into a sick role for a very
long time or even permanently. Second, Parsons’s discussion ignores the fact, mentioned earlier, that our social location in
society in the form of social class, race and ethnicity, and gender affects both the likelihood of becoming ill and the quality
of medical care we receive. Third, Parsons wrote approvingly of the hierarchy implicit in the physician-patient
relationship. Many experts say today that patients need to reduce this hierarchy by asking more questions of their
physicians and by taking a more active role in maintaining their health. To the extent that physicians do not always
provide the best medical care, the hierarchy that Parsons favored is at least partly to blame.

The Conflict Approach

The conflict approach emphasizes inequality in the quality of health and of health-care delivery (Conrad, 2009). As noted
earlier, the quality of health and health care differ greatly around the world and within the United States. Society’s
inequities along social class, race and ethnicity, and gender lines are reproduced in our health and health care. People
from disadvantaged social backgrounds are more likely to become ill, and once they do become ill, inadequate health care
makes it more difficult for them to become well. As we will see, the evidence of inequities in health and health care is vast
and dramatic.

The conflict approach also critiques the degree to which physicians over the decades have tried to control the practice of
medicine and to define various social problems as medical ones. Their motivation for doing so has been both good and
bad. On the good side, they have believed that they are the most qualified professionals to diagnose problems and treat
people who have these problems. On the negative side, they have also recognized that their financial status will improve if
they succeed in characterizing social problems as medical problems and in monopolizing the treatment of these problems.
Once these problems become “medicalized,” their possible social roots and thus potential solutions are neglected.

Several examples illustrate conflict theory’s criticism. Alternative medicine is becoming increasingly popular (see Chapter
18 “Health and Medicine”, Section 18.4 “Medicine and Health Care in the United States”), but so has criticism of it by the
medical establishment. Physicians may honestly feel that medical alternatives are inadequate, ineffective, or even
dangerous, but they also recognize that the use of these alternatives is financially harmful to their own practices. Eating
disorders also illustrate conflict theory’s criticism. Many of the women and girls who have eating disorders receive help
from a physician, a psychiatrist, a psychologist, or another health-care professional. Although this care is often very
helpful, the definition of eating disorders as a medical problem nonetheless provides a good source of income for the
professionals who treat it and obscures its cultural roots in society’s standard of beauty for women (Whitehead & Kurz,
2008).

Obstetrical care provides another example. In most of human history, midwives or their equivalent were the people who
helped pregnant women deliver their babies. In the 19th century, physicians claimed they were better trained than
midwives and won legislation giving them authority to deliver babies. They may have honestly felt that midwives were
inadequately trained, but they also fully recognized that obstetrical care would be quite lucrative (Ehrenreich & English,
2005). In a final example, many hyperactive children are now diagnosed with ADHD, or attention deficit/hyperactivity
disorder. A generation or more ago, they would have been considered merely as overly active. After Ritalin, a drug that
reduces hyperactivity, was developed, their behavior came to be considered a medical problem and the ADHD diagnosis
was increasingly applied, and tens of thousands of children went to physicians’ offices and were given Ritalin or similar
drugs. The definition of their behavior as a medical problem was very lucrative for physicians and for the company that
developed Ritalin, and it also obscured the possible roots of their behavior in inadequate parenting, stultifying schools, or
even gender socialization, as most hyperactive kids are boys (Conrad, 2008; Rao & Seaton, 2010).

According to conflict theory, physicians have often sought to define various social problems as medical problems. An example is the development of the
diagnosis of ADHD, or attention deficit/hyperactivity disorder.

birgerking – What I Really Do… ADD/ADHD – CC BY 2.0.

Critics of the conflict approach say that its assessment of health and medicine is overly harsh and its criticism of
physicians’ motivation far too cynical. Scientific medicine has greatly improved the health of people in the industrial
world; even in the poorer nations, moreover, health has improved from a century ago, however inadequate it remains
today. Although physicians are certainly motivated, as many people are, by economic considerations, their efforts to
extend their scope into previously nonmedical areas also stem from honest beliefs that people’s health and lives will
improve if these efforts succeed. Certainly there is some truth in this criticism of the conflict approach, but the evidence of
inequality in health and medicine and of the negative aspects of the medical establishment’s motivation for extending its
reach remains compelling.

The Interactionist Approach

The interactionist approach emphasizes that health and illness are social constructions. This means that various physical
and mental conditions have little or no objective reality but instead are considered healthy or ill conditions only if they are
defined as such by a society and its members (Buckser, 2009; Lorber & Moore, 2002). The ADHD example just discussed
also illustrates interactionist theory’s concerns, as a behavior that was not previously considered an illness came to be
defined as one after the development of Ritalin. In another example, in the late 1800s opium use was quite common in the
United States, as opium derivatives were included in all sorts of over-the-counter products. Opium use was considered
neither a major health nor legal problem. That changed by the end of the century, as prejudice against Chinese Americans
led to the banning of the opium dens (similar to today’s bars) they frequented, and calls for the banning of opium led to
federal legislation early in the 20th century that banned most opium products except by prescription (Musto, 2002).
In a more current example, an attempt to redefine obesity is now under way in the United States. Obesity is a known
health risk, but a “fat pride” movement composed mainly of heavy individuals is arguing that obesity’s health risks are
exaggerated and calling attention to society’s discrimination against overweight people. Although such discrimination is
certainly unfortunate, critics say the movement is going too far in trying to minimize obesity’s risks (Saulny, 2009).

The symbolic interactionist approach has also provided important studies of the interaction between patients and health-
care professionals. Consciously or not, physicians “manage the situation” to display their authority and medical
knowledge. Patients usually have to wait a long time for the physician to show up, and the physician is often in a white lab
coat; the physician is also often addressed as “Doctor,” while patients are often called by their first name. Physicians
typically use complex medical terms to describe a patient’s illness instead of the more simple terms used by laypeople and
the patients themselves.

Management of the situation is perhaps especially important during a gynecological exam. When the physician is a man,
this situation is fraught with potential embarrassment and uneasiness because a man is examining and touching a
woman’s genital area. Under these circumstances, the physician must act in a purely professional manner. He must
indicate no personal interest in the woman’s body and must instead treat the exam no differently from any other type of
exam. To further “desex” the situation and reduce any potential uneasiness, a female nurse is often present during the
exam (Cullum-Swan, 1992).
Critics fault the symbolic interactionist approach for implying that no illnesses have objective reality. Many serious health
conditions do exist and put people at risk for their health regardless of what they or their society thinks. Critics also say the
approach neglects the effects of social inequality for health and illness. Despite these possible faults, the symbolic
interactionist approach reminds us that health and illness do have a subjective as well as an objective reality.