Health and Illness

1. Our physical selves have socially constructed meanings and are also affected by social forces.
2. Health is influenced by where and when we live, as well as by what statuses we hold in our society.
3. Social, cultural, and subcultural factors affect just about everything having to do with health and illness.

1. Types of illness
   1. Acute diseases: diseases that have a sudden onset, may be briefly incapacitating, and are either curable or fatal.
   2. Chronic diseases: diseases that develop over a longer period of time and may not be detected until symptoms occur later in their progression.
2. Approaches to medical treatment
   1. The U.S. health care system is characterized by three approaches:
      1. Curative or crisis
      2. Preventative
      3. Palliative
   2. Curative or crisis medicine: treats the disease or condition once it has manifested.
   3. Preventative medicine: aims to avoid or forestall the onset of disease by taking preventive measures, often including lifestyle changes.
   4. Palliative medicine: focuses on symptom and pain relief and providing a supportive environment for critically ill or dying patients.

1. Medicalization: the process of transforming problems that were once not considered medical conditions into illnesses over time.
   1. It transforms natural parts of the human life cycle (e.g., birth and death) into something unfamiliar that we fear we cannot handle on our own.
   2. Addiction, obesity, and mental or emotional problems were all once considered a result of weak will, but are now seen as diseases that can be controlled through medicine.
2. The social construction of mental illness
   1. In the fourteenth century, mental illness was thought to be caused by demon possession.
   2. In Colonial America, mental illness was treated by bleeding and long-term induced vomiting.
   3. In the 1930s, lobotomies were used to cure mental illness.
   4. Today, we treat mental illness as a problem of brain chemistry which is managed through medicine.

1. Epidemiology: the study of the social aspect of disease patterns.
   1. Epidemiologists collect and analyze data in order to understand the causes of a particular illness, how it is communicated, the factors affecting its development and distribution in a population, where it is likely to spread, and what the most effective interventions might be.
2. Epidemic: A significantly higher number of cases of a particular disease occur during a particular time period than might otherwise be expected.
   1. For example, the Ebola epidemic of 2014
3. Pandemic: A significantly higher number of cases of a disease also spreads through an especially large geographical region spanning many countries or even continents.
   1. For example, HIV/AIDS
4. The global climate change may contribute to the spread of diseases.
   1. People migrating for access to food, water, and other resources bring diseases to new areas.
   2. Scarce resources mean that people are malnourished and live in close quarters where infectious diseases bread and spread quickly.
   3. Vector organisms: animals like mosquitoes, ticks, and birds that carry and spread pathogens (germs or other infectious agents) in a given area.

1. Intersections of class
   1. People with higher SES not only can afford more and better health care, but they also have greater access to other resources that positively impact their health.
   2. People with lower SES have substantially higher rates of disease with higher death rates and shorter life expectancy.
   3. Highly educated adults have lower mortality rates than those who are less educated, and this holds across racial/ethnic, gender, and age groups.
2. Intersections of race
   1. One of the largest and most persistent health disparities among racial and ethnic groups is the infant mortality rate. Black women experience infant mortality rates two times higher than white women.
   2. Blacks and Hispanics are less likely to be able to afford health insurance, and are more often exposed to unhealthful surroundings at work and in residential neighborhoods.
3. Intersections of gender
   1. Health is one place where gender inequality benefits women over men.
   2. Women are generally healthier and enjoy a longer life expectancy in spite of having a lower SES than men.
   3. Men and women suffer from diseases like cancer and diabetes in about equal numbers.
   4. Women are 40 percent more likely to develop mood or anxiety disorders.
4. Inequality and the problem of food deserts
   1. Food desert: a community in which the residents have little to no access to fresh, affordable, healthy foods.
   2. Most food deserts are located in densely populated, urban areas that may have convenience stores and fast-food restaurants, but no grocery stores or other outlets for fresh fruits, vegetables, meats, and other healthy foods.
   3. Food deserts are often in neighborhoods that are predominantly low-income or nonwhite in population.
   4. In the 1960s–1970s, grocery chains left cities for the suburbs due to perceived problems of security, profitability, real-estate costs, and parking.
   5. Deprivation amplification: when our individual disease risks (based on our heredity and physiology) are amplified by social factors.

1. American Medical Association (AMA)
   1. To the general public, an organization that makes health recommendations.
   2. To medical professionals, a trade union that creates the rules and regulations governing medical licensure.
2. Milton Friedman criticized the AMA for
   1. limiting admissions to medical schools despite a serious shortage of physicians.
   2. restricting medical licensing to advance the interests of physicians.
   3. being a monopolizing organization that reduced the quantity and quality of medical care by forcing the public to pay more for medical services due to the lack of qualified physicians.
3. Institutional contexts
   1. The institutional context can have a powerful effect on the interactions that occur within it.
   2. Once the medical institution labels an individual as “sick” or “unwell,” all of the individual’s actions are interpreted under that label.
   3. For example, in Rosenhan and Goffman’s studies, once people were diagnosed as mentally ill, they became unable to convince others that they are normal because the institutional label is sticky.
   4. Patients are robbed of their agency and autonomy at a time when they are most defenseless and least able to assert themselves.
4. Doctor–patient relations
   1. The institutional setting does not always exert the type of power we might think it does over the interactions that occur within it.
   2. The people involved in interactions must establish who has power or status, as they must also distinguish good from bad.
   3. Female doctors are more likely to adhere to clinical guidelines, order preventive tests, and to provide more patient-centered care, but they face gender discrimination in medical school and in the workforce.
   4. The rules, roles, and other elements of institutional order are emergent and situational: created and maintained in interaction.
5. The sick role
   1. Sick role: the actions and attitudes that society expects from someone who is ill.
   2. Talcott Parsons argues that the sick role is, from a functional perspective, a form of deviance.
      1. The patient is exempted from regular responsibilities and is not held responsible for the illness.
      2. The patient has a new set of duties, which include seeking medical help as part of an earnest effort to recuperate and get back to normal.
      3. Those who do not attempt to recuperate are labeled deviant.
   3. The sick role has changed due to advances in medical technology.
   4. Genetic testing has identified those who are not sick, but are at risk for certain diseases.
   5. The at-risk role demonstrates that the experience of health and illness is not as straightforward as Parsons originally hypothesized.

1. Health Care Reform in the United States
   1. Health care reform has been identified as a national priority since 1974, but it was not until March 2010 that the Patient Protection and Affordable Care Act (ACA) was signed into law. This act has been controversial and is being challenged.
   2. Affordable Care Act (ACA)
      1. Allows children to remain on their parents’ insurance through age twenty-six
      2. Bans insurance companies from denying coverage to those with preexisting conditions
      3. Closes loopholes that once allowed insurance companies to deny or limit coverage to people who become ill
      4. Bans lifetime spending caps
      5. Bans rescission (canceling coverage only after a person gets sick)
      6. Created federal and state-run insurance exchange systems to cover the unemployed, self-employed, and others without insurance.
   3. Until the ACA, the United States was the last wealthy, industrialized nation without some form of universal health coverage.
2. Complementary and alternative medicine (CAM)
   1. Complementary medicine: a group of medical treatments, practices, and products that can be used in conjunction with conventional Western medicine.
   2. Alternative medicine: a group of medical treatments, practices, and products that are used instead of conventional Western medicine.
   3. CAM involves everything from deep breathing and herbal remedies to chiropractic and massage.
   4. This growing field is slowly gaining legitimacy in the world of conventional medicine, but is still generally not covered by medical insurers.
   5. Integrative medicine: combination of conventional medicine with complementary practices and treatments that have proven to be safe and effective.
3. Medical ethics
   1. Bioethics: the study of controversial moral or ethical issues related to scientific and medical advancements.
      1. The Human Genome Project raises the issue of genetic testing, and whether parents should be able to choose whether or not to bear a disabled child.
   2. Eugenics: an attempt to selectively manipulate the gene pool in order to produce and “improve” human beings through medical science.
   3. Medical technology is advancing rapidly enough to cause a cultural lag or delay in the legal, ethical, and social issues surrounding its use.
4. End of life
   1. The ability to prolong life can sometimes make it more difficult to distinguish between “living” and “dying” (e.g., persistent vegetative states) and hence to respond appropriately to those who are close to death.
   2. Organizations such as Compassion and Choices and Final Exit promote the right of terminally ill patients to invoke medically assisted suicide.
   3. As of 2017, California, Colorado, District of Columbia, Montana, Oregon, Vermont, and Washington allowed physicians to prescribe certain patients life-ending medication.

      I.          Cultural Definitions of Health and Illness

1. Health: the extent to which a person experiences a state of mental, physical, and social well-being.
   1. Not just the absence of illness but a positive sense of soundness.
   2. Interplay of psychological, physiological, and sociological factors in a person’s sense of well-being.
2. Medicine: an institutionalized system for the scientific diagnosis, treatment, and prevention of illness.
   1. Identifying and treating physiological and psychological conditions that prevent a person from achieving a state of normal health.
3. Preventive medicine: medicine emphasizing a healthy lifestyle that will prevent poor health before it occurs.

   II.          The Sick Role

1. Sick roles: cultural definitions of the appropriate behavior of and response to people labeled as sick.
   1. Example: sick role of mental illness varies greatly.
2. Talcott Parsons: sick role includes right to be excused from social responsibilities and other “normal” social roles.
   1. Suggests that illness is both biologically and socially defined.
3. Sick person has a societal obligation to try to get well and seek competent medical help.
4. Goffman’s dramaturgical approach: sick person, doctor, nurse, family, all expected to act a certain way when someone is sick and behave according to certain roles.

III.          The Social Construction of Illness

1. Sick role is culturally determined. Illnesses that are culturally defined as legitimate entitle those who contract them to adopt the role of sick person.
   1. Example: cancer, heart disease.
2. Those defined as legitimate can change over time.
   1. Example: alcoholism.
3. Drug addiction often criminalized rather than medicalized.
   1. Example: pregnant women who use drugs.

1. Feminist standpoint theory and construction of female ills.
2. Medicine long dominated by men and medicinal knowledge reflects a male standpoint.
   1. Examples: Brain-Ovary thesis, female hysteria as a category of 19th century.

 IV.          Health Care and Public Health in the United States

1. Health care: all activities intended to sustain, promote, and enhance health.
   1. Provision of medical services, policies that minimize violence and the chance of accidents, clean, nontoxic environment, ecological protection, availability of clean water, fresh air, and sanitary living conditions.

   V.          Health and Public Safety Issues

1. Provision of health care greatly differs by society.
2. S. government spends money in to construct safe highways, provide clean drinking water, regulate air and ground pollution.
3. Laws regulate working conditions to promote healthy and safe environments.
4. Compared to most other modern countries, the United States is more violent.
   1. Gun violence is a serious problem.
      1. United States has the 21st highest rate of gun violence in the world.
      2. Homicides due to gun violence are 25 times higher than in 22 other developed countries.
      3. Homicide is a leading cause of death among young African American males and the majority of this violence is perpetrated using guns.
   2. At least 85% of victims of domestic violence are women.
      1. Average three U.S. women are murdered by their partner every day.
      2. One in three adolescent females reported being physically and/or sexually abused by a dating partner.
   3. Different social groups experience different degrees of violence or safety.

 VI.          Social Inequalities in Health and Medicine

1. Health follows a social class curve: poor people are likely to suffer more chronic illnesses and die earlier.
2. Poverty affects health, food security, housing stability, and maltreatment.
3. Lower income people more likely to:
   1. Live in areas with high levels of air pollution, which raises the risk of asthma, heart disease, and cancer.
   2. Live in areas with a higher risk of exposure to lead paint.
   3. Live in areas with a greater exposure to violence and the associate mental and physical health problems.
   4. Have jobs that involve physical and health risks.
4. Have less healthy diets: inexpensive foods may be highly processed, fatty, and high in sugar.
   1. Fresh fruits and vegetables and lean meats may be unavailable or too expensive.
   2. May lack time and resources to shop and cook healthy meals.
5. May lack access to safe places for active outdoor play and exercise.
6. Less likely to see symptoms of illness as requiring a physician.
7. Racial minorities suffer poorer health than Whites.
   1. Overall life expectancy: 78.8.
   2. White women: 81.1; Black women: 78.1.
   3. White men: 76.3; Black men: 71.8.
8. Starts at birth: poor mothers are less likely to have access to prenatal care. African American infant mortality rate twice as high as Whites.
9. S. medical establishment has used poor minorities to advance science.
   1. Example: Tuskegee Syphilis Study, radiation studies by government during Cold War, the contaminated water in Flint, Michigan.

VII.          Access to Health Care

1. Notable proportion of people unable to access regular care for prevention and treatment of disease.
2. In 2010, over 16% of people in the United States lacked health-care insurance.
3. Changing labor market and economic structure: favors part-time or contractual employment, fewer benefits such as employer-based coverage.
4. Substantial number has access through government-funded programs.
   1. Medicare: about 47.8 million ages 65+ and about 9 million younger residents with disabilities.
   2. Medicaid: 5 million 2018.
      1. Designed to assist low-income people of all ages.
   3. Working poor and low-income employees often shut out of insurance coverage altogether.
      1. Work in service sector that provides little or no insurance benefits to employees, while earning too little to afford self-coverage but too much to qualify for government health coverage.
      2. More likely to have health problems that affected past ability to get insurance coverage, because of “preexisting conditions.”
   4. Patient Protection and Affordable Care Act (ACA) passed by President Obama in 2010.
      1. Designed to make everyone be insured; requires people to buy insurance coverage; eliminates use of preexisting conditions to deny coverage, extends parental insurance coverage for dependent children until age 26.
      2. ACA has been source of heated political debate:
         1. In support: will expand insurance coverage to a broader swath of people; support expansion through new state-level insurance markets; keep prices down; fewer burdens on emergency room care.
         2. Opposed: government is overstepping the limits of its powers in requiring that people purchase health insurance or pay a penalty tax; infringement on freedom; portrayed as socialized medicine.
         3. Both supporters and opponents have concerns about cost of U.S. health-care system.
      3. The United States spends more per capita on health care than most economically developed states but its health indicators compare poorly.
      4. Can Technology Expand Health Care Access?
         1. Technological innovations are bringing health care into people’s homes.
         2. Innovations such as Doctor on Demand, American Well, and AskMD offer a range of services, from the opportunity to ask questions by text and receive a free medical response to an online appointment that requires payment for a consultation.
         3. Potential pitfalls include lack of application to acute or urgent needs and access issues for those without technology.

VIII.          Sociology and Issues of Public Health in the United States

1. Public health: the science and practice of health protection and maintenance at a community level.
   1. Control hazards and habits that harm health and well-being of the population.

 IX.          Smoking

47. One of most profitable industries in the United States is the tobacco industry with revenues at about $47.1 billion.
48. Tobacco is number one cause of premature death in the United States, 480,000 lives annually.
49. Morbidity: rate of illness in a particular population.
50. Mortality: rate of death in a particular population.
51. Smoking rate has been dropping. About 15.5% of the population.
52. Advertising of cigarettes constructs and reinforces gender and age stereotypes.
    1. Male smokers: independence, ruggedness, machismo, Marlboro Man.
    2. Female smokers: elegant, chic, playful, carefree.
    3. Age: for teens, symbol of maturity, coolness, rebellion.
53. Conflict Perspective: profitable to businesses–generous contributors to political candidates.
54. Functionalist Perspective: positively functional in its creation of jobs, profits from tobacco trade used to finance American Revolution.

   X.          Obesity

1. Major cause of mortality, second only to smoking.
2. About 65% of adults between the ages of 20 and 74 are overweight or obese.
3. Rates vary by gender and ethnicity.
4. Children’s rate of obesity has risen even faster and is twice what it was in the late 1970s.
   1. One in six children are obese.
   2. Experience social ostracism and may suffer serious health effects.
   3. Popularity of sedentary activities, such as video games, social media, and television.
5. S. families eat less at home and more at take-out and fast-food restaurants.
6. Cheaper meals but larger portion sizes and less nutritious.
7. Federal subsidies for food production have subsidized obesity:
   1. Favor meat and dairy: 75% of funding.
   2. Over 10% support sugar, oils, starches, and alcohol.
   3. Less than a third of 1% support the growing of vegetables and fruits.
8. Physician and scientist Deborah A. Cohen (2014) traces obesity to an “obesogenic environment” and points to three key components:
   1. Factors like agricultural advances have led to an abundance of cheap food.
   2. Availability of food, particularly junk food, has grown: more than 41% of retail stores, including hardware stores, furniture stores, and drugstores, offer food.
   3. Food advertising has vastly expanded. Grocery stores today earn more from companies paying for prime display locations than from consumers buying groceries.
9. Obesity is also linked to social class.
   1. Poor access to nutritious food is more likely to be manifested in obesity than emaciation in the United States.
   2. Macro-level effects, of lost productivity when employees miss work because of obesity.
10. Conflict Perspective: who benefits? Food industry, $209 billion annual medical costs associated with obesity.

 XI.          Teen Pregnancy and Birth

19. In 2016, just under 209,800 births to mothers between ages of 15 and 19.
20. Most are unmarried when they give birth.
21. Rate continues to be high but is dropping continuously and considerably.
22. Teen mothers have worse health, more pregnancy complications, and more stillborn, low-weight, or medically fragile infants.
23. Giving birth early and outside marriage compounds risk that young women and their children will become or remain poor.
    1. About 30% of all female-headed households in the United States live below the poverty line, compared to 6% of married-couple families.
24. Parenthood is a leading cause of dropping out of school among teenage women.
    1. 50% of women who become mothers before 18 earn a high school diploma.
    2. Fewer than 2% earn a college degree by age 30.
25. Poverty is itself a risk factor for teenage motherhood: estimated 80% of teen mothers grew up in low-income households.
    1. Poor teens have a higher incidence of early sexual activity, pregnancy, and birth.
    2. Opportunity costs–educational or other opportunities lost because of early motherhood–may seem low for a poor young woman.
26. Edin and Kefalas: for many poor young women, early motherhood is embraced as an honorable and desirable choice.
    1. Limited pool of stable, marriageable partners, motherhood seen as reasonable and available option.
27. Rates of teen motherhood has declined, increased use of condoms, small drops in sexual activity.

XII.          The Sociology of HIV/AIDS

1. Acquired immunodeficiency syndrome (AIDS) provides case study of the social construction of illness.
2. Perceptions of HIV/AIDS victims have varied across time, depending on who its most visible victims have been.
3. Intertwined with gender inequality, poverty, violence and conflict, and medical industry, and profits in a globalizing world.
4. Estimated 36 million persons around the globe have HIV/AIDS.
   1. About 1.8 million new infections that year.
      2010. 11% decrease in new infections since 2010.
   2. Since 2015, AIDS-related deaths have dropped by 48%.
   3. Situation varies by region.
      1. New infections have dropped in sub-Saharan Africa, but have risen in East and Central Europe, Central Asia, the Middle East, and North Africa.

XIII.          Gender, Sexuality, and HIV/AIDS

1. Half of new infections are now diagnosed among women.
2. In some regions, women’s infection rates outpace men’s:
   1. Sub-Saharan Africa, two-and-a-half times as many adolescent girls were newly infected with HIV than boys between the ages of 15 and 19 in 2014.
3. In some cultures, may be acceptable or desirable for men to have multiple partners both before and after marriage and marriage becomes a risk for HIV for women.
4. Many women lack accurate knowledge of sexually transmitted diseases, worsened by widespread illiteracy.
   1. May not know how to protect themselves or their partners.
5. New York Times Magazine article: the “down low”: culture of Black men who present as heterosexual but engage in homosexual activity.
   1. Black male bisexuality and homosexuality little discussed and little accepted.
   2. May not know HIV status and risk spreading to partners, both men and women.

XIV.          Poverty and HIV/AIDS

1. Epidemic in China as thousands of rural villagers sold their blood for money under unsafe and unsterile conditions.
   1. 55,000 commercial blood and plasma donors infected with HIV.
   2. Migrant workers living away from home may seek out services of prostitutes, who may be infected.
2. Women in the sex trade, some of whom have been trafficked and enslaved, are highly vulnerable to HIV/AIDS.
   1. Little protection from rape and limited power to negotiate safe sex.
3. Poor nations especially vulnerable as well.
   1. HIV prevalence in adults aged 15–49: 10% in Botswana; 14% in Lesotho; 18% in Swaziland.
   2. High rate of infection and death among young and middle-aged adults also means that countries are left with a diminished workforce.

XV.          Violence and HIV/AIDS

1. Risk to women of contracting HIV/AIDS is increased by situations of domestic violence.
2. Rape of men by other males, not uncommon in prison settings, can also be implicated in the spread of the infection.
3. Incidence of HIV/AIDS in prisons often significantly higher than the incidence of the disease in the noninstitutionalized population.
   1. Sharing needles, consensual male sexual activity, sexual violence.

XVI.          Global Issues in Health and Medicine

1. Spread of disease knows no national boundaries.
   1. Bubonic plague or “Black Death” came to Europe by way of Asia, eliminating a third of the European population in only 20 years.
   2. European conquerors of the Americas brought syphilis and other diseases, virtually eliminating the indigenous population.
   3. S. soldiers returning from Europe at the end of World War I carried previously unknown influenza strains, killed an estimated 20 million people worldwide.
   4. Tuberculosis returning with new treatment-resistant strains brought by immigrants from poor nations.
   5. S. government researchers deliberately infected hundreds of Guatemalan mental patients with gonorrhea and syphilis for observational purposes and encouraged them to transfer their infections to others.
2. Global triumph over many diseases, sanitation, clean water, sewage systems, knowledge about the importance of diet.
   1. World Health Organization’s “Health for All by the Year 2000” succeeded in immunizing half the world’s children against measles, polio, and four other diseases.
   2. Gates Foundation vaccinated 78% of children in the world against diphtheria, tetanus, and whooping cough. 99% of the way toward eradicating polio.
3. AIDS epidemic: rapid global spread to both industrialized and developing nations.
   1. Treatment and prevention–cooperation among countries and organizations.
   2. Global market in treatment dominated by Western pharmaceutical companies.
      1. Guard patent rights on drug therapies shown to be most effective.
   3. Malaria: one of most threatening diseases in developing countries.
      1. Kills over 800,000 people every year.
      2. Individual, community, national levels.
         1. Individual: costly in drugs, travel to clinics, lost time at work or school, burial.
         2. Governments: loss of tourism and productive members of society; cost of public health interventions.
      3. Chronic disease often ignored in developing countries; just 1% of donor assistance targeted chronic disease.
         1. 80% of global deaths from chronic diseases take place in low- and middle-income countries.
         2. Growing rates of obesity and of smoking.

XVII.          Why Should Sociologists Study Health?

1. No one is isolated from diseases spawned in distant places or their consequences; acute illnesses of poverty can be found alongside chronic maladies of affluence.
2. Sociology offers tools to examine sociological antecedents of public health problems. With sociology, we can:
   1. Recognize social roots of disease and illness.
   2. Analyze ways that medical issues like HIV/AIDS intersect with phenomena like gender inequality, gender stereotypes, violence, and poverty.
   3. Examine global obesity epidemic sociologically–individuals’ choices about food and fitness are made in social and economic environments that profoundly affect those choices.
   4. Imagine creative, constructive responses to health problems.