Medical Sociology
MEDICAL SOCIOLOGY
Over the past several decades medical sociology has become a major subdiscipline of sociology, at the same time assuming an increasingly conspicuous role in health care disciplines such as public health, health care management, nursing, and clinical medicine. The name medical sociology garners immediate recognition and legitimacy and, thus, continues to be widely used—for instance, to designate the Medical Sociology Section of the American Sociological Association—even though most scholars in the area concede that the term is narrow and misleading. Many courses and texts, rather than using the term "sociology of medicine," refer instead to the sociology of health, health and health care, health and illness, health and medicine, or health and healing. The study of medicine is only part of the sociological study of health and health care, a broad field ranging from (1) social epidemiology, the study of socioeconomic, demographic, and behavioral factors in the etiology of disease and mortality; to (2) studies of the development and organizational dynamics of health occupations and professions, hospitals, health maintenance and long-term care organizations, including interorganizational relationships as well as interpersonal behavior, for example, between physician and patient; to (3) the reactions of societies to illness, including cultural meanings and normative expectations and, reciprocally, the reactions of individuals in interpreting, negotiating, managing, and socially constructing illness experience; to (4) the social policies, social movements, politics, and economic conditions that shape and are shaped by health and disease within single countries, as well as in a comparative, international context.
The rise of contemporary medical sociology can be traced back to the immediate post-World War II period, when science and medicine were dominant cultural forces, fueling a modern optimism that many of society's ills could be eliminated. Several key contributions during the 1950s gave credibility and spurred scholarly interest in the newly developing subfield. Koos's The Health of Regionville (1954) and Hollingshead and Redlich's Social Class and Mental Illness (1958) addressed the connections between social circumstances and health status, and were instrumental in establishing a strong tradition of sociological research focusing on the social determinants of health. The finding that individuals in the lower socioeconomic levels of society experience greater morbidity and mortality has turned out to be one of the most consistent of these patterns. Also during this time, a number of sociology's most prominent theorists turned their attention to health and health care. They approached the topic not because their primary interest was in health care or medicine, but out of a generic interest in authority and the maintenance of social order. Robert Merton, Everett Hughes, and Anselm Strauss all studied professional organizations and socialization during the 1950s, focusing primarily on physicians and the process of medical education (Merton et al. 1957; Becker et al. 1961).
The theoretical work of the 1950s most influential for medical sociology was undoubtedly Talcott Parsons's The Social System (1951). In it, Parsons recognized illness as a major threat to the stability and productivity of societies and introduced the "sick role" concept to describe the social regulation of sickness and explain the mechanism through which individuals are induced to return to productive activity. Parsons argued that because sick persons were unable to perform their expected social roles, they were subject to being negatively sanctioned. On the other hand, if they had not intended to become ill and were motivated to get well, then, according to Parsons's analysis, they could claim and be granted temporary exemption without blame from normally expected role responsibilities. Rather than being held accountable for failure to perform, they would be excused as sick. Parsons's work generated enormous sociological interest because of its analysis of illness and medical care in terms of their broad social consequences and because of its focus on the structure and functions of social roles. His work also expanded the theoretical foundations of medical sociology by provoking equally compelling work from contrasting perspectives. Elliot Freidson in Profession of Medicine (1970) analyzed the dominance of the medical profession, suggesting that power relations in health care were fundamentally contentious. He saw physicians as rising to dominate health care through a process of struggle with competitors in which they prevailed largely because they gained the support of political institutions, limiting the role of competing occupations. In contrast to the fixed roles in structural-functional theory, Freidson argued that illness definitions and illness behavior were socially constructed through a process of negotiation. The debate over structure and agency represented in these early contributions laid theoretical pathways for subsequent scholarship and solidified medical sociology's ties to some of the central issues of the discipline.
Medical sociology became established in only a few sociology departments during its early years, typically in elite universities. It was not until the 1970s that most graduate departments of sociology began to offer medical sociology. Today, sociology courses on health and medicine can be found in nearly every graduate program in the United States as well as in many other nations, notably the United Kingdom and Germany (Bloom 1986). Research funding to support the growth of medical sociology in many countries has come from government sources. In the 1960s and 1970s, U.S. medical sociology expanded in part because social science research was held in favor by the federal government as well as by influential private foundations. Major funding sources at that time included the National Institute of Mental Health (NIMH) and, later, the National Center for Health Services Research (NCHSR).
It has been argued that the fortunes of medical sociology have shifted in relation to the social-medical environment (Pescosolido and Kronenfeld 1995). Until the1980s, medical sociology experienced relatively fertile conditions due in part to the fact that the health care system was dominated by professional medicine. Access to health care was the primary health policy concern, while research funding priorities focused on the biomedical and psychosocial aspects of disease, disease prevention, and patient care. This environment encouraged medical sociologists to pursue quantitative research, including surveys, national-level studies, and multivariate statistical models that predicted utilization of health services and the effects of risk factors and other variables. Two particular lines of medical sociology research gained prominence as a result of this focus. The first involved researchers studying utilization patterns for health services. There were two groups, each using a somewhat different explanatory model. Marshall Becker and his colleagues employed the Health Belief Model, a cognitive framework originated by Rosenstock (1966) and eventually applied in research, to explain a wide variety of preventive and health-related behaviors (Becker and Maiman 1975). Ronald Andersen developed the somewhat broader sociobehavioral model (1995), which included health beliefs but also emphasized economic factors and health needs. The second line of research concerned quantitative studies of social stress. David Mechanic, one of the founders of medical sociology, pioneered sociological research on stress and mental health as early as the 1960s (Mechanic and Volkart 1961). The "stress process" group that emerged in the late 1970s, however, was closer to an interface of psychology and sociology. Using multivariate analyses, they examined the relationships among stress (Aneshensel 1992), social support (Turner and Marino 1994), and coping (Pearlin and Schooler 1978). Much of this research was published in the American Sociological Association's Journal of Health and Social Behavior, beginning in the late 1970s and continuing into the present (Thoits 1995).
The social-medical environment in the United States changed dramatically in the 1980s, threatening the autonomy and authority of physicians (Starr 1982). The federal government's increasing role in financing health care (through the Medicare and Medicaid programs) combined with rapidly escalating health care costs and the concern expressed by business, leading to a major federal policy shift. Rather than inequality in access and social factors in illness, public policy attention was now placed on cost control and the cost effectiveness of care. NIMH support for medical sociology was weakened, and soon afterward, the NCHSR became the Agency for Health Care Policy and Research with an agenda of research focused on managed care and evidence-based medicine. Research funding priorities gravitated from the behavioral and social sciences to economics and clinical medicine and epidemiology. No doubt these changes contributed to critical claims in the late 1980s and the 1990s, that medical sociology research had become fragmented.
The significance of health system changes for the profession of medicine became a hotly debated topic among medical sociologists during the 1980s. The controversy was sparked in 1985 with the publication of McKinley and Arch's "Toward the Proletarianization of Physicians," in which the authors argued that historical processes of bureaucratic rationalization were finally reaching medicine, irreversibly eroding the functional autonomy of physicians. This directly challenged Freidson's medical dominance perspective (1970). Also part of the debate was the hypothesis, introduced by Marie Haug (1976), that physicians had lost authority due to the increasing knowledge and medical sophistication of patients. A plethora of articles appeared, identifying and discussing at length various hypothesized changes in medical dominance and authority and culminating, though by no means ending, with a special issue of the Milbank Quarterly in 1988.
Much of the early growth of medical sociology can be attributed to scholars located outside sociology departments in medical schools, nursing schools, schools of public health, and health administration programs. These individuals addressed research concerns and questions that were of paramount importance in their respective settings, such as the reasons people engage in health-promoting behavior, define themselves as sick, use health services, and comply with medical treatment. They contributed to medical and health care disciplines by bringing attention to the significance of culture and human interaction in producing the meaning of illness and shaping illnessrelated behavior (Zola 1966; Mechanic 1995). They dispelled the image of the physician as a purely rational scientist. Sociologists also contributed to the development of social epidemiology, mapping the social patterns of disease, and adding social factors to the causal understanding of mortality and chronic diseases (Berkman and Syme 1979). A third group studied hospitals and health care organizations, bringing an organizational sociology perspective into the field of health services research (Flood and Fennell 1995).
Robert Straus, a medical school sociologist, introduced in 1957 what became for many years a popular way of dividing the subfield. Sociologists such as those described above were designated "sociologists in medicine" in contrast to sociologists of medicine who were typically based in sociology departments. According to Straus, sociologists of medicine used medical settings to address questions of sociology while sociologists in medicine used sociological knowledge to address questions of medicine. Today, the boundaries between those working in health care settings and those in academic departments of sociology are blurred; sociologists in both venues conduct applied research as well as research that contributes to basic sociological theorizing. In fact, it is quite common for medical sociologists to have multiple academic appointments. On the other hand, the distinction remains valid in the pressure to conduct research that reflects the priorities of the dominant group. Medical sociologists in medicine often engage in research shaped by medical issues and a biomedical approach, whereas those in sociology have an easier time posing sociological questions grounded in sociological theory. In its early years, medical sociology was sometimes dismissed by other academic sociologists as "applied" sociology, based on the rather elitist assumption that its research did not contribute to the basic body of knowledge of the discipline and that it lacked a theoretical body of its own. Today, there is greater understanding of the links between basic sociological theory and medical sociology (Gerhardt 1989). Medical sociology concepts such as "medicalization" have added to the broader understanding of social order and social control (Conrad 1992). Medicine and the other health care disciplines recognize sociology as a valuable discipline that can contribute much to the understanding and application of health care. Academic sociology has come to regard the sociology of medicine as a fruitful area of specialization.
It is in their role of social critic that medical sociologists encounter the greatest resistance from mainstream medicine and health care. Critical medical sociology emerged from both Marxist and social constructionist traditions within the discipline (Waitzkin 1989; Brown 1995). Symbolic interactionists and labeling theorists in the 1960s saw that, despite the Parsonian notion of the sick role, many types of illness and disability were responded to socially as forms of deviance. Goffman's concept of stigma (1963) explored the relationship between labeling and identity as a process of managing spoiled identity. One of the most powerful explanatory concepts in medical sociology, stigma has been used for decades to capture the experience of mental illness, alcoholism, physical disability, and many types of chronic illness. Goffman (1961) and Zola (1972), among others, turned the standard notion of medical care as a service on its head by arguing that medicine functions as an institution of social control. Despite strong microsociological interest in the social construction and social consequences of medical labels (i.e., diagnoses), the professional power of physicians made it exceedingly difficult for sociologists to study these processes until the 1980s. What could be studied, however, using the broader, cultural meaning of social construction, were processes of medicalization. Building on the social control perspective of Zola and others, a number of studies examined the processes through which nonmedical phenomena—such as childbirth, excessive drinking, children's active behavior, and menstrual distress—became medical phenomena, with diagnostic criteria and specific medical treatments.
Bias in medicine and social inequality in health care have been concerns of critical medical sociology as well as of corresponding social movements initiated to improve health care. Gender analyses, especially those from a feminist perspective, offered a critical, alternative perspective on the medical profession (Lorber 1984) and the health care system (Zimmerman and Hill 1999), as did research on the women's health movement (Ruzek 1978; Weisman 1998). This work examined the relationship between cultural ideas about gender, medical knowledge, and gender stratification systems; pointed out that the division of labor in medicine is also a gendered division of labor; and observed that the factors that often make women sick are linked to their social roles and disadvantaged social circumstances. Other critical perspectives were offered by disability researchers (Zola 1982) and by researchers focusing on the health and health care of racial and ethnic minorities (Hill 1992; Williams and Collins 1995).
The critical perspective in medical sociology was fortified by Mishler's (1981) critique of the biomedical model, in which he argued that medicine was itself a culture, based as much on customs, social norms, and values as on scientific fact. Mishler's view of medicine as socially constructed led to a concern with medical discourse analysis (1984) and, for some researchers, to the study of illness narratives. Departing from the political and critical concerns of the 1980s and 1990s, these scholars have conducted in-depth, qualitative studies of illness experience, incorporating aspects ignored by their predecessors, such as emotions and the body (Charmaz 1991; Weitz 1991). The "postmodern turn" that swept over academic humanities and social science departments in the latter decades of the twentieth century influenced a number of symbolic interactionist and social constructionist medical sociologists. Working at the interface of constructionism and postmodernism, these scholars created new ways to explore the relationship between illness and identity (Frank 1995; Hall 1998).
Reviewing the literature of medical sociology reveals an unusually broad range of topics, theoretical perspectives, and research methodologies. Beyond the contributions reviewed above, medical sociologists are also active in international comparative research studying health systems or specific health care sectors within them. They are involved in health policy research both at the federal and at the local community level; they are studying alternative health care providers and their clients as well as various forms of folk medicine and lay care; and they are doing research on informal caregivers and the process of care work. Even these additions do not exhaust the parameters of the field. Medical sociology has enriched and continues to enrich the discipline of sociology, as well as making unique and valuable contributions to important policy issues and to the needs of health care professionals, managers, and patients.
references
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Aneshensel, Carol S. 1992 "Social Stress: Theory and Research." Annual Review of Sociology 18:15–38.
Avison, William R., and R. Jay Turner 1988 "Stressful Life Events and Depressive Symptoms: Disaggregating the Effects of Acute Stressors and Chronic Strains." Journal of Health and Social Behavior 29:253–264.
Becker, Howard S., Blanche Geer, Everett C. Hughes, and Anselm Strauss 1961 Boys in White: Student Culture in Medical School. Chicago: University of Chicago Press.
Becker, Marshall, and Lois Maiman 1975 "Sociobehavioral Determinants of Compliance with Health and Medical Care Recommendations." Medical Care 13:10–24.
Berkman, Lisa, and Leonard Syme 1979 "Social Network, Host Resistance and Mortality: A Nine Year Follow-up Study of Alameda County Residents." American Journal of Epidemiology 190:186–204.
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Brown, Phil 1995 "Naming and Framing: The Social Construction of Diagnosis and Illness." Journal of Health and Social Behavior (Extra Issue):34–52.
Charmaz, Kathy 1991 Good Days, Bad Days: The Self in Chronic Illness and Time. New Brunswick, N.J.: Rutgers University Press.
Conrad, Peter 1992 "Medicalization and Social Control." Annual Review of Sociology 18:137–162.
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——1963 Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, N.J.: Prentice Hall.
Hall, Lisa Cox 1998 "Illness, Identity and Survivorship: Modern and Postmodern Breast Cancer Narratives." Illness, Crisis and Loss 6:255–274.
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Hill, Shirley A. 1992 Managing Sickle Cell Disease in Low Income Families. Philadelphia: Temple University Press.
Hollingshead, August B., and Frederick Redlich 1958 Social Class and Mental Illness. New York: John Wiley.
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——1982 Missing Pieces: A Chronicle of Living with a Disability. Philadelphia, Pa.: Temple University Press.
Mary K. Zimmerman
Medical Sociology
MEDICAL SOCIOLOGY
Some have argued that medical sociology should be thought of as a loosely connected network of disparate subgroups rather than as a single discipline. Many medical sociologists tend to argue against certain axioms in the biomedical model of health and illness. They reject the reductivist approach of biomedicine, which claims that health and disease are natural phenomena that exist in the individual body rather than in the interaction of the individual and the social world; they reject the doctrine of specific etiology, the vision that disease can be induced by introducing a single specific factor into a healthy animal; and they reject biomedicine's claim to scientific neutrality. Like sociology in general, subgroups within medical sociology vary according to dichotomies such as human agency versus social structure, conflict versus consensus, and idealism versus realism. Subgroups also vary according to subject matter, thus the sociology of medicine can be distinguished from the sociology of health and illness, the sociology of healers, and the sociology of the health care system. Medical sociologists also distinguish between the sociology of health, the study of health, illness, and health care to further sociological theory; and sociology in health, the use of sociological insights to complement biomedicine's objectives and priorities. There are four often interrelated areas of research in medical sociology: the social production of health and illness, the social construction of health and illness, postmodern perspectives on health and illness, and the study of the health care system and its constituent parts.
Research in the social production of health and illness tends to explore variations in biomedical indicators of health such as self-reported health status and morbidity or mortality statistics. Social epidemiology shows that the distribution of disease is related to the structure of social inequalities (i.e., to occupational class, socioeconomic status, gender, marital status, age, ethnicity, area of residence, housing, family structure, and employment status), although it does little to explain these microlevel relationships.
The political economy perspective incorporates a broader political and economic framework, arguing that relations of domination within patriarchal capitalism create conditions of deprivation within which some people must struggle to maintain health. It claims that there is a contradiction between the pursuit of health and the pursuit of profit. It notes the large differentials in health found among social classes, sometimes pointing to unhealthy work environments of the lower classes as an explanation, and also notes the strong relationship found among Western countries between aggregate health and degree of income inequality. This perspective has been criticized, however, for failing to recognize the substantial health gains that have accompanied capitalist development and for proposing a scenario with little opportunity for intervention or change.
Social relations (such as social support for individuals and social capital or social cohesion for communities) have been investigated as determinants of the health of individuals and communities. There is also strong empirical support for the importance of lifestyle practices and behaviors embedded in social environments and cultural contexts. On a global scale, some authors argue that capitalist imperialism influences the presence and distribution of illness in developing nations, through the transfer of modern medicine, industry, and technology from the West, which is motivated in part by profit-driven pharmaceutical companies, for example. Finally, some authors investigate the role of Western medicine in creating as well as preventing illness. They argue that improvements in health have come mainly from nonmedical factors, and that medicine reproduces the legitimacy of the dominant social order by serving as a means of social control.
Social construction research views illness behaviors and the experience of health and illness as social states. Interactionist theory argues that people bestow meaning on their interactions with others—that selves are emergent and socially constructed. An early sociological contribution was the distinction between disease (an objective state), illness (the subjective experience of disorder), and sickness (the social state associated with being ill). Talcott Parsons's sick role, a social role with certain rights and obligations for those so labeled, shows the power of medicine to define illness and shows that illness is a form of social deviance. Subsequent work has introduced core sociological concepts such as deviance, labeling, career, medicalization, socialization, self, and identity to the field. Interactionist approaches have been criticized for neglecting the hard realities of power and politics and for their cognitivist bias, sharply separating the mind and body.
Postmodernist thought rejects binary oppositions, instead focusing on a shifting reality with multiple truths. Foucauldian social constructionism of claims that diseases are fabrications of powerful discourses wherein individuals explore the boundaries of their self-identity, engaging in the endless task of self-transformation. Others argue that the body is a liquid commodity, an object of circulating capital, in a new world of hyperreality filled with new forms of technology. The sociology of the body stresses the re-entrance of the physical body within sociological discourse, exploring how socially structured physiology affects social behavior and vice versa. These perspectives are criticized for their lack of an ethic, extreme relativism and abstraction, and lack of attention to the greater political context.
Some micro-level concerns when studying the health care system are entry into and experience with the health care system and patient-practitioner relationships, which have shifted focus from the provider's interest in compliance to a power-based perspective. Some argue that medicalization (providers defining needs) impinges on patient autonomy and acts as a form of social control directing deviance into controllable channels. Others explore the behaviors of providers, the management of uncertainty in practice, and implicit theories of professional knowledge. A prevailing theme at the meso-level, the interactional region between the face-to-face encounter and the wider social structure, is medical dominance, the power of medicine to define matters in its own interests, applied to the study of professions, occupations, hospitals, and medical schools, for example. Some have studied the adoption of a cloak of competence in the socialization of medical students. Community involvement in planning and decision making—the democratization of medical care—received attention in the late 1990s. Finally, some macro-level concerns are the role of multinational pharmaceutical companies in shaping the nature of health care and the reasons for and historical development of health insurance.
Gerry Veenstra
(see also: Cultural Norms; Social Networks and Social Support; Sociology in Public Health; Values in Health Education )
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