After reading this Chapter, you should be able to:
- develop an introductory understanding of the sorts of topics that social scientists working in the area of health typically explore,
- begin to critically analyse approaches to health and wellbeing, drawing on different theoretical perspectives, and
- critically situate health and wellbeing in their social contexts by thinking about how social characteristics can contribute to the health and welfare of people and groups.
How do social scientists understand health and wellbeing?
The sociology of health is concerned with the social institution of medicine and, as White (2017: 44) describes, it “ranges over a wide territory: [interrogating, for example] how some conditions come to be called diseases; the experience of being sick or ill; the organisation of the medical profession; the ways in which health policies are produced; and the workings of hospitals.” The sociology of health has changed its focus and emphasis over time.
In the 1950s sociology concerning medicine was most often focused on assisting the “dissemination of medical knowledge” and encouraging “patient compliance with medical directives” (White 2017: 37). There was very little questioning or critique of the institution of medicine or the way it was practiced; health institutions were generally considered to be benevolent and, as Talcott Parsons (1902-1979) (the so-called ‘father’ of structural functionalism) argued, the institution of medicine tended to be uncritically regarded as being crucially important in operating alongside other institutions to support a harmonious and self-sustaining society.
Before you move on, grab a pen and paper and write down a short (~30 word) critique of the structural functionalist perspective of medicine (which prevailed in the 1950s, as described above) as a purely benevolent social institution. Think about your critique; what have you included, and what might you have missed?
From the 1960s onwards, social scientists became more interested in how conflict and power might also be expressed through the field of medicine. For instance, consider the concept of medicalisation. The concept of ‘medicalisation’ refers to the process by which some aspects of the human condition come to be defined as representing ‘illness’ or ‘sickness’. In turn, labelling someone as ‘ill’ enables a whole range of medical interventions to take place. From the 1960s onwards, sociologists began to become interested in how labels of illness might reflect social norms around behaviours, instead of illness per se.
In one of his earlier books called Madness and Civilisation, Foucault (1961) talked about how the idea of ‘madness’ (or mental illness) has changed over time, from being treated in some societies as a sign of wisdom or spiritual connectedness to being classified as dangerous, where individuals were confined (e.g. in asylums) and subjected to heavily invasive ‘corrective’ treatments, such as frontal lobotomies, the use of mind-altering drugs, and electro convulsion therapy (ECT) (White 2017: 39).
The very act of defining something as an illness can be thought of as the process of constructing a new ‘truth’, which influences how we think about ourselves and others. Consider the following:
- Homosexuality was only removed from the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) in 1973 — until then, it was considered and treated as a mental illness, worthy of intervention and correction (Drescher 2015). (If you’re interested in reading more, see Out of DSM: Depathologizing Homosexuality.)
- For a large part of the 19th and 20th centuries, women’s ‘hysteria’ was considered a legitimate medical condition, where women apparently suffered from a “wide array of symptoms including sexual desire and the nebulous ‘tendency to cause trouble’.” (Maines 2012) It invited a range of invasive treatments, such as confinement and (later) ECT (also see Tasca et al. 2012).
- In your reading, White (2017: 46) describes what was, during the 19th century, referred to as ‘Drapteomania’. The symptoms of this so-called disease involved African American slaves running away from plantations on which they were forced to work. As White (2017: 46) describes, “the white plantation owners called in the doctors. And the doctors, as skilled practitioners of a technical and scientific practice, diagnosed the condition as a disease and prescribed a remedy: the removal of both big toes, thereby making running a physical impossibility.”
Both Goffman (1961) and Foucault (1961) questioned the role of medicine as “a value-loaded system of social control operating under the guise of science” (White 2017: 39). Foucault wrote from first-hand experience as someone who had suffered from mental illness and who had also worked in a mental health hospital during his younger years. In the views of these (and other) scholars, symptoms of illness (the definitions of which have changed considerably over time) mark someone as ‘deviant’ — that is as deviating from the ‘norm’ of a ‘healthy’ body and mind. Thus, medicine operates (alongside other social institutions) to recognise and punish deviance and to, in turn, encourage conformity with hegemonic social and cultural norms. This kind of thinking took sociologists further towards conflict and critical theory perspectives of health and medicine, which recognised that the social institution of medicine itself could both reflect and reinforce hegemonic social norms. However, the institution of medicine did so in ways that appealed to the evidence base of scientific ‘truths’ and was, therefore, particularly powerful.
In anthropology, too, the field of medical anthropology developed to answer questions at the intersection of culture, society, health and illness around the world as well as critique existing structures, institutions and norms that perpetuate(d) prevailing norms as discussed above. Medical anthropology explores how social, political, economic, and cultural factors influence people’s experiences of health, illness, and healthcare. Medical anthropologists aim to understand the complex relationships between biological, social, and cultural factors that determine health outcomes, well-being and broader societal views on health issues. Medical Anthropology as a seperate sub-field emerged in the mid-20th century and has since grown to encompass a wide range of topics, from the study of local healing practices to the examination of global public health issues, such as pandemics. At the heart of anthropological studies is the examination of the cultural meanings of health and illness and the ways in which people’s experiences thereof are shaped by their cultural beliefs, values, and practices. To gain this understanding, medical anthropologists use ethnography. This is the key qualitative method in anthropology to study cultures, societies and people, often for extended periods of time, to gain a deep and nuanced understanding of the particular issue investigated. Medical anthropologists use participatory observation, interviews and comparative case studies to understand the social, cultural, and historical contexts of health and illness around the world.
Since the 1960s a key theme for medical anthropology has been the study of the unequal distribution of health and illness, and the ways in which social and political factors contribute to health disparities. Paul Farmer (1959-2022) has been instrumental in highlighting the structural issues at play that determine people’s health. He was a social justice activist and global health pioneer, co-founding Partners in Health in 1987 to address a lack of medical facilities in Haiti. Farmer was a medical doctor and anthropologist, which meant he understood both the daily medical needs of patients and practitioners as well as the broader historical, economic, political, social and cultural barriers to better healthcare for marginalised people around the world. He and his organisation have pioneered ways of delivering low cost but good healthcare to remote and underserved regions, even helping to rebuild Rwanda’s entire healthcare system. Within the academic field his most significant contributions have been to our understanding of the social determinants of health and the impact of structural violence on global health.
After watching the above video, consider the following questions:
1) What are some key areas of focus for a sociology of health and medicine?
2) How might other social institutions, such as family or work, or other characteristics, such as gender, shape how you understand and respond to symptoms of illness?
Social determinants of health
The movement towards more critical perspectives of health also led sociologists to recognise that health was influenced by not just individual, but also structural factors, such as social class and other social determinants. White (2017: 41) described this critique as follows:
The medical model explained disease and illness as the outcome of the invasion of a germ or virus into the individual’s body. The cure was the administration of drugs or the application of technologically based treatments.
[However] That individuals became sick because of the invasion of a germ or virus, and could be cured by the application of medically prescribed regimens, over-looked the fact that individuals also lived in social groups that may have had as much to do with their illness and diseases as germs or viruses. It is quite possible to be infected with a germ or virus and not be diseased. This finding is particularly well established in the case of tuberculosis, where occupation and living conditions play a large part in whether or not the disease develops.
Before you read on, think about some key social factors that might determine someone’s health over their life course. Write a list of the things that come to mind.
After writing your list, watch What Makes Us Healthy? Understanding the Social Determinants of Health (YouTube, 6:27) below. Once you’ve watched the video, revisit your list. Would you add anything else to either your own list, or to what is discussed/described in the video?
Structural determinants, like socioeconomic and political context, can influence (and be influenced by) individual characteristics, such as gender, race, and class. Thus, our position in society is a key factor in determining whether we will experience good or poor health over our lives. As White (2017: 44) explains, “For a sociologist, what people get sick of, how they are treated, and what they die of are a product not of their personality or, primarily, of their biology, but of their position in a set of power relationships that are formed out of access to those social goods which guarantee the quality of life.”
Thus, those studying a sociology of health tend to focus on health through the lens of their sociological imaginations. This encourages them to think through the nested realities of individuals and how these can influence health and wellbeing over time. In particular — and building on the key themes we’ve discussed in previous weeks — this enables us to move beyond conceptions of medicine as the “value-free workings of a disinterested scientific practice” and instead explore it as “the product of social relationships” (White 2017: 48).
Bond and Singh (2020) talk about this in your reading with regard to the health and wellbeing of Indigenous peoples in Australia. The authors question the Closing the Gap ‘refresh’, which began in 2019, on the grounds that it would be unlikely to result in policies that address the structural and social determinants of poorer health for Indigenous peoples. While direct engagement by Indigenous peoples in the refresh process was considered positive, Bond and Singh (2020: 198) state:
Whether such engagement will engender the radical reimagining required to transform persisting Indigenous health disparities remains to be seen. There is a danger that the engagement of Indigenous peaks [i.e. Indigenous peak representative organisations], many of which are reliant on federal funding, will be used to embellish a policy agenda that effectively maintains the status quo and, further, will be held responsible for any future policy failings in Indigenous health.
Think about this line of argument in relation to the systemic issues of racism and inequality that are raised in the below video and activity. Can a mere ‘refresh’ of Closing the Gap targets address these kinds of deeply embedded and racialised structural inequalities that are a primary contributor to poorer health outcomes for Indigenous Australians? Bond and Singh (2020: 199) argue, for instance, that:
Epidemiological discourses that describe the gap [in health outcomes between Indigenous and non-Indigenous Australians] are limited in their ability to close the gap because the mechanism by which the gap is made real — race — is barely understood by the epidemiologist.
- White, K. 2017. The development of the sociology of health. In. An introduction to the sociology of health and illness (3rd edition). London: Sage Publications, pp. 36-58.
- Bond, C. and Singh, D. 2020. More than a refresh required for closing the gap of Indigenous health inequality. Medical Journal of Australia, 212(5): 198-199
- Bond, C. and Singh, D. 2019. Canada-Australia Indigenous health and wellness racism working group – discussion paper and literature review. University of Queensland and Lowitja Institute: Brisbane.
- Munro, J. and Hoffstaedter, G. ‘COVID-19 and “medical citizenship”: How the pandemic is generating new forms of belonging and exclusion‘.