How can we define health? Imagine a continuum with health on one end and death on the other. In the preamble to its 1946 constitution, the World Health Organization defined health as a “state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity” (Leavell and Clark 1965:14). In this definition, the “healthy” end of the continuum represents an ideal rather than a precise condition. Along the continuum, people define themselves as healthy or sick on the basis of criteria established by themselves and relatives, friends, co-workers, and medical practitioners. Because health is relative, then, we can view it in a social context and consider how it varies in different situations or cultures. Why is it that you may consider yourself sick or well when others do not agree? Who controls definitions of health and illness in our society, and for what ends? What are the consequences of viewing yourself (or of being viewed) as ill or disabled? By drawing on four sociological perspectives—functionalism, conflict theory, interactionism, and labeling theory—we can gain greater insight into the social context that shapes definitions of health and the treatment of illness. Functionalist Approach
Illness entails breaks in our social interactions, both at work and at home. From a functionalist perspective, being sick must therefore be controlled, so that not too many people are released from their societal responsibilities at any one time. Functionalists contend that an overly broad definition of illness would disrupt the workings of a society.
In U.S. society, people who are sick are supposed to stay home and… Sickness requires that one take on a social role, if only temporarily. The sick role refers to societal expectations about the attitudes and behavior of a person viewed as being ill. Sociologist Talcott Parsons (1951, 1975), well known for his contributions to functionalist theory, outlined the behavior required of people who are considered sick. They are exempted from their normal, day-to-day responsibilities and generally do not suffer blame for their condition. Yet they are obligated to try to get well, which includes seeking competent professional care. This obligation arises from the common view that illness is dysfunctional, because it can undermine social stability. Attempting to get well is particularly important in the world’s developing countries. Modern automated industrial societies can absorb a greater degree of illness or disability than horticultural or agrarian societies, in which the availability of workers is far more critical (Conrad 2009b). According to Parsons’s theory, physicians function as gatekeepers for the sick role. They verify a patient’s condition either as “illness” or as “recovered.” The ill person becomes dependent on the physician, because the latter can control valued rewards (not only treatment of illness, but also excused absences from work and school). Parsons suggests that the physician–patient relationship is somewhat like that between parent and child. Like a parent, the physician helps the patient to enter society as a full and functioning adult (Weitz 2007). use your sociological imagination
Describe some situations you have witnessed that illustrate different definitions of the “sick role." The concept of the sick role is not without criticism. First, patients’ judgments regarding their own state of health may be related to their gender, age, social class, and ethnic group. For example, younger people may fail to detect warning signs of a dangerous illness, while elderly people may focus too much on the slightest physical malady. Second, the sick role may be more applicable to people who are experiencing short-term illnesses than to those with recurring, long-term illnesses. Finally, even simple factors, such as whether a person is employed, seem to affect one’s willingness to assume the sick role—as does the impact of socialization into a particular occupation or activity. For example, beginning in childhood, athletes learn to define certain ailments as “sports injuries” and therefore do not regard themselves as “sick.” Nonetheless, sociologists continue to rely on Parsons’s model for functionalist analysis of the relationship between illness and societal expectations of the sick (Curry 1993).
Conflict theorists observe that the medical profession has assumed a preeminence that extends well beyond whether to excuse a student from school or an employee from work. Sociologist Eliot Freidson (1970:5) has likened the position of medicine today to that of state religions yesterday—it has an officially approved monopoly of the right to define health and illness and to treat illness. Conflict theorists use the term medicalization of society to refer to the growing role of medicine as a major institution of social control (Conrad 2009a; McKinlay and McKinlay 1977; Zola 1972, 1983). The Medicalization of Society
Social control involves techniques and strategies for regulating behavior in order to enforce the distinctive norms and values of a culture. Typically, we think of informal social control as occurring within families and peer groups, and formal social control as being carried out by authorized agents such as police officers, judges, school administrators, and employers. Viewed from a conflict perspective, however, medicine is not simply a “healing profession”; it is a regulating mechanism. How does medicine manifest its social control? First, medicine has greatly expanded its domain of expertise in recent decades. Physicians now examine a wide range of issues, among them sexuality, old age, anxiety, obesity, child development, alcoholism, and drug addiction. We tolerate this expansion of the boundaries of medicine because we hope that these experts can bring new “miracle cures” to complex human problems, as they have to the control of certain infectious diseases. The social significance of this expanding medicalization is that once a problem is viewed using a medical model—once medical experts become influential in proposing and assessing relevant public policies—it becomes more difficult for common people to join the discussion and exert influence on decision making. It also becomes more difficult to view these issues as being shaped by social, cultural, or psychological factors, rather than simply by physical or medical factors (Caplan 1989; Conrad 2009a). Second, medicine serves as an agent of social control by retaining absolute jurisdiction over many health care procedures. It has even attempted to guard its jurisdiction by placing health care professionals such as chiropractors and nurse-midwives outside the realm of acceptable medicine. Despite the fact that midwives first brought professionalism to child delivery, they have been portrayed as having invaded the “legitimate” field of obstetrics, both in the United States and Mexico. Nurse-midwives have sought licensing as a way to achieve professional respectability, but physicians continue to exert power to ensure that midwifery remains a subordinate occupation (Scharnberg 2007). Inequities in Health Care
The medicalization of society is but one concern of conflict theorists as they assess the workings of health care institutions. As we have seen throughout this textbook, in analyzing any issue, conflict theorists seek to determine who benefits, who suffers, and who dominates at the expense of others. Viewed from a conflict perspective, glaring inequities exist in health care delivery in the United States. For example, poor areas tend to be underserved because medical services concentrate where people are wealthy. Similarly, from a global perspective, obvious inequities exist in health care delivery. Today, the United States has about 27 physicians per 10,000 people, while African nations have fewer than 1 per 10,000. This situation is only worsened by the brain drain—the immigration to the United States and other industrialized nations of skilled workers, professionals, and technicians who are desperately needed in their home countries. As part of this brain drain, physicians, nurses, and other health care professionals have come to the United States from developing countries such as India, Pakistan, and various African states. Conflict theorists view their emigration out of the Third World as yet another way in which the world’s core industrialized nations enhance their quality of life at the expense of developing countries. One way the developing countries suffer is in lower life expectancy. In Africa and much of Latin America and Asia, life expectancy is far lower than in industrialized nations (Bureau of the Census 2009a; World Bank 2009).
Figure 15-1 Infant Mortality Rates In Selected Countries
Conflict theorists emphasize that inequities in health care have clear life-and-death consequences. From a conflict perspective, the dramatic differences in infant mortality rates around the world (Figure 15-1) reflect, at least in part, unequal distribution of health care resources based on the wealth or poverty of various nations. The infant mortality rate is the number of deaths of infants under 1 year old per 1,000 live births in a given year. This measure is an important indicator of a society’s level of health care; it reflects prenatal nutrition, delivery procedures, and infant screening measures. Still, despite the wealth of the United States, at least 46 nations have lower infant mortality rates, among them Canada, Sweden, and Japan. Conflict theorists point out that, unlike the United States, these countries offer some form of government-supported health care for all citizens, which typically leads to greater availability and use of prenatal care (MacDorman and Mathews 2009). use your sociological imagination
From a sociological point of view, what might be the greatest challenge to reducing inequities in health care? Interactionist Approach
From an interactionist point of view, patients are not passive; often, they actively seek the services of a health care practitioner. In examining health, illness, and medicine as a social institution, then, interactionists engage in micro-level study of the roles played by health care professionals and patients. Interactionists are particularly interested in how physicians learn to play their occupational role. According to Brenda L. Beagan (2001), the technical language students learn in medical school becomes the basis for the script they follow as novice physicians. The familiar white coat is their costume—one that helps them to appear confident and professional at the same time that it identifies them as doctors to patients and other staff members. Beagan found that many medical students struggle to project the appearance of competence that they think their role demands.
Sometimes patients play an active role in health care by failing to follow a physician’s advice. For example, some patients stop taking medications long before they should. Some take an incorrect dosage on purpose, and others never even fill their prescriptions. Such noncompliance results in part from the prevalence of self-medication in our society; many people are accustomed to self-diagnosis and self-treatment. On the other hand, patients’ active involvement in their health care can sometimes have very positive consequences. Some patients read books about preventive health care techniques, attempt to maintain a healthful and nutritious diet, carefully monitor any side effects of medication, and adjust the dosage based on perceived side effects. Labeling Approach
Labeling theory helps us to understand why certain people are viewed as deviants, “bad kids,” or criminals, whereas others whose behavior is similar are not. Labeling theorists also suggest that the designation “healthy” or “ill” generally involves social definition by others. Just as police officers, judges, and other regulators of social control have the power to define certain people as criminals, health care professionals (especially physicians) have the power to define certain people as sick. Moreover, like labels that suggest nonconformity or criminality, labels that are associated with illness commonly reshape how others treat us and how we see ourselves. Our society attaches serious consequences to labels that suggest less-than-perfect physical or mental health (H. Becker 1963; C. Clark 1983; H. Schwartz 1994). A historical example illustrates perhaps the ultimate extreme in labeling social behavior as a sickness. As enslavement of Africans in the United States came under increasing attack in the 19th century, medical authorities provided new rationalizations for the oppressive practice. Noted physicians published articles stating that the skin color of Africans deviated from “healthy” white skin coloring because Africans suffered from congenital leprosy. Moreover, the continuing efforts of enslaved Africans to escape from their White masters were classified as an example of the “disease” of drapetomania (or “crazy runaways”). The prestigious New Orleans Medical and Surgical Journal suggested that the remedy for this “disease” was to treat slaves kindly, as one might treat children. Apparently, these medical authorities would not entertain the view that it was healthy and sane to flee slavery or join in a slave revolt (T. Szasz 2010). According to labeling theorists, we can view a variety of life experiences as illnesses or not. Recently, premenstrual syndrome, post-traumatic stress disorders, and hyperactivity have been labeled medically recognized disorders. In addition, the medical community continues to disagree over whether chronic fatigue syndrome constitutes a medical illness. TAKING SOCIOLOGY TO WORK
Lola Adedokun, Independent Consultant, Health Care Research
Probably the most noteworthy medical example of labeling is the case of homosexuality. For years, psychiatrists classified being gay or lesbian not as a lifestyle but as a mental disorder subject to treatment. This official sanction became an early target of the growing gay and lesbian rights movement in the United States. In 1974, members of the American Psychiatric Association voted to drop homosexuality from the standard manual on mental disorders (Conrad 2009a). Table 15-2 summarizes four major sociological perspectives on health and illness. Although they may seem quite different, two common themes unite them. First, any person’s health or illness is more than an organic condition, since it is subject to the interpretation of others. The impact of culture, family and friends, and the medical profession means that health and illness are not purely biological occurrences, but sociological occurrences as well. Second, since members of a society (especially industrial societies) share the same health care delivery system, health is a group and societal concern. Although health may be defined as the complete well-being of an individual, it is also the result of