Sociology of Health and Illness Lecturer: Seppo Poutanen

1
Sociology of Health and IllnessLecturerSeppo
Poutanen

• K.9. or M.2., 2 op/1 ov (notify of your
  preferences in the exam paper)
• 22 hours of lectures 30. 10. 4. 12.
• PUB 5, Monday 14-16, Wednesday 12-14
• The first exam 11. 12., the second exam 18. 12.
  (you can write in either English or Finnish)
• The third exam on the department exam day in
  January 2007 (registration in advance)

2
Content of the course (I)

• 1. CONCEPTS OF HEALTH, ILLNESS, DISEASE,
  SICKNESS
• General definitions, lay definitions, scientific
  and theoretical definitions
• 2. THE BIOMEDICAL MODEL OF DISEASE
• Specific etiology, generic disease, deviation
  from the normal, scientific neutrality

3
Content of the course (II)

• 3. THE SOCIAL MODEL OF HEALTH
• Criticism of the biomedical model a human being
  as an organistic whole partly constituted by
  social factors sense of coherence
  value-ladenness
• 4. PRELIMINARIES ON SOCIOLOGY OF HEALTH AND
  ILLNESS
• To fit health and illness in existing
  sociological theories or to use them to develop
  something new?

4
Content of the course (III)

• 5. BASIC THEORETICAL APPROACHES TO SOCIOLOGY OF
  HEALTH AND ILLNESS
• Functionalism, marxism, social constructionism
• 6. SOME SPECIAL SUBJECTS IN SOCIOLOGY OF HEALTH
  AND ILLNESS
• (In case we have time)

5
Some definitions of concepts from OED Online (I)

• health a) well-being, welfare, safety,
  deliverance
• b) soundness of body that condition in which its
  functions are duly and efficiently discharged
• illness a) bad or unhealthy condition of the
  body (or, formerly, of some part of it) the
  condition of being ill b) bad moral quality,
  condition, or character wickedness, depravity
  evil conduct badness

6
Some definitions of concepts from OED Online (II)

• well-being the state of being or doing well in
  life happy, healthy, or prosperous condition
  moral or physical welfare (of a person or
  community)
• disease a condition of the body, or of some part
  or organ of the body, in which its functions are
  disturbed or deranged a morbid physical
  condition

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What is health? (I)(Blaxter Health, Polity 2004)

• I dont think I know when I am healthy, I only
  know if I am ill (office worker aged 28)
• My health is a reflection of my lifestyle I
  need to be spiritually, mentally, emotionally and
  physically whole to be truly healthy. I believe
  complete wholeness is only attainable through
  reconciliation with God (herbalist)

8
What is health? (II)(Blaxter Health, Polity
2004)

• Health is to feel proud when you can go out
  and you can hold you head up, look good. You
  dont have so many hang-ups, and you think
  straight (computer operator aged 25)
• Health is being able to walk around better and
  doing some work in the house when my knees let
  me (woman aged 79)

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What is health? (III)(Blaxter Health, Polity
2004)

• illness is a kind of rest, when you can be free
  of your everyday burdensFor me, illness is
  breaking off from social life, from life outside
  and social obligations (unknown)
• What is health? That is a silly question!
  (driver aged 39)

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Scientific/theoretical attempts at a general
definition of health (I) (Blaxter Health,
Polity 2004)

• health is normality, which is disrupted by any
  physiological, biochemical or psychological
  deviance
• But normal is not necessarily good, and abnormal
  is not necessarily bad
• health is abnormality, because practically nobody
  is totally healthy ever
• But minor inconvenience is clearly less
  significant than e.g. terminal illness

11
Scientific/theoretical attempts at a general
definition of health (II) (Blaxter Health,
Polity 2004)

• health is function, because to be healthy is to
  manage ones everyday tasks freely and without
  pain
• But everyday tasks vary considerably, and
  environments rather than people may be
  non-functional
• health can also mean balance of bodys processes
  and systems, obedience to social norms, living in
  the silence of ones organs

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Illness, disease, sickness, the sick role
(Blaxter Health, Polity 2004)

• illness is the subjective experience of ill
  health
• disease is the medically defined pathology
• sickness is the social role of those defined as
  diseased or ill
• the sick role refers to the set of rights and
  obligations that surround illness and shape the
  behaviour of doctors and patients Gabe et al.
  Key Concepts in Medical Sociology, Sage 2004

13
Some complications (Blaxter Health, Polity
2004)

• absence of disease may be part of health, but
  health is usually taken to be more than absence
  of disease (asymmetry between the concepts)
• illness without disease or sickness, disease
  without illness or sickness
• health as a state am I healthy/ill now/today
  etc.?
• health as a status am I basically a healthy or
  an unhealthy person?

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The modern biomedical model of disease (Blaxter
Health, Polity 2004)

• (1) Doctrine of specific etiology
• But multiple causes and intervening factors
  behind diseases
• (2) Assumption of generic disease
• But symptoms often treated like disease
• (3) Deviation from the normal
• But normality/abnormality is no self-evident but
  value-laden fact
• (4) Scientific neutrality
• But medicine is embedded in society

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The modern social model of health (I) (Blaxter
Health, Polity 2004)

• WHO declared in the year 1948 health is a state
  of complete physical, mental and social
  well-being, and not merely the absence of disease
  or infirmity.
• the biomedical model was criticised for being i)
  repair- not prevention-oriented, ii)
  technology-centred, iii) expensive, iv)
  injurious, v) naively utopian

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The modern social model of health (II) (Blaxter
Health, Polity 2004)

• Basic assumptions
• (1) a human being must not be taken as a
  mechanistic combination of biophysical functions
  but as an organistic whole, in which the sum
  counts for more than its parts
• (2) social factors do not affect a humans health
  from outside but partly constitute her/him and
  her/his health

17
The modern social model of health (III)
(Blaxter Health, Polity 2004)

• A persons sense of coherence consists of
  comprehensibility, manageability and
  meaningfulness (Antonovsky Health, Stress and
  Coping, Jossey-Bass 1979)
• the stronger sense of coherence a person has, the
  better she maintains her health and displays a
  psychic resistance to stress

18
The modern social model of health whose
coherence, whose well-being?

• social models of health most clearly include
  value choices concerning good life, and so
  questions of health and illness become
  intertwined with ethics and politics
• a trouble with health campaigns people want more
  or something else from their lives than just
  narrowly defined health

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Preliminaries on sociology of health and illness
(I)

• the relationship between sociology and questions
  of health and illness as a two-way road
• i) the task is to fit health and illness as
  social phenomena into existing theoretical and
  explanatory frameworks of sociology, or
• ii) the task is to create apt sociological
  concepts and theories for grasping health and
  illness as social phenomena

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Preliminaries on sociology of health and illness
(II)

• Far from being seen as a peripheral area of
  social life, health and illness are now rightly
  regarded as being at the centre of the study of
  private troubles and public issues. More than
  this, much that is exciting in sociology is
  gaining from, and contributing to, the field of
  health and illness. This is true for both theory
  and empirical research. (Bury Gabe The
  Sociology of Health and Illness, A Reader,
  Routledge, 2004, p. 1.)

21
Basic theoretical approaches in sociology of
health and illness functionalism

• sociological functionalism puts focus on the
  consequences instead of causes of empirical
  social phenomena
• how is it possible for a society to exist and
  continue its existence through time?
• Parsons introduced the sick role in his The
  Social System, 1951

22
Sociological functionalism

• societys subsystems according to (structural)
  functionalism
• i) the economy societal adaptation to its
  action and non-action environmental systems
• ii) the polity societal goal attainment
• iii) the societal community the integration of
  its diverse social components
• iv) the fiduciary system processes and units
  that function to reproduce societal culture

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The function of the modern medical practice

• an important subsystem of society with its own
  functional character
• too low a general level of health and too high an
  incidence of illness is dysfunctional from the
  point of view of society
• The function of medical practice ... is to
  help maintain an optimal level of health in
  society. (Gabe et al. Key Concepts in..., Sage,
  2004, p. 92)

24
Functionalism some causes of illness and the
doctor-patient relationship

• in a complex modern society a person can
  experience conflicts related to her different
  social roles
• if the conflict is prolonged it can cause
  stress-related and psychosomatic diseases
• a doctor and her patient work harmoniously
  together to get the patient back to his normal
  life

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Some criticism of functionalism

• the sick role concept does not grasp the
  situation of a chronic well, because the latter
  cannot remain in the sick role
• there are other important actors in medical
  systems than just doctors and patients
• maintenance of optimal health in a society would
  require more prevention of illness and promotion
  of health than actually is the case

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Basic theoretical approaches in sociology of
health and illness marxism

• the mode of production of material life
  determines the general character of the social,
  political and spiritual processes of life (Karl
  Marx, 1859)
• the key antagonistic axis in capitalist mode of
  production is between the social classes of
  capitalists (they own the means of production)
  and workers (they must sell their labour power to
  capitalists to earn some living)

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Marxism (conflict theory, materialist
perspective, political economy perspective)

• critical functionalism social institutions exist
  to maintain capitalist society, which is
  something we should get rid of
• to positive (Parsonsian) functionalism the
  medicine and related institutions are profoundly
  good, but to critical marxist functionalism
  they are profoundly bad

28
Medicalization from marxist tradition to
general use

• medicalization describes a process by which
  non-medical problems become defined and treated
  as medical problems, usually in terms of illness
  or disorders - Gabe et al. Key Concepts in
  Medical Sociology, Sage 2004
• medicalization may happen at i) conceptual, ii)
  institutional and/or social interactional level

29
The five stages of medicalization(Conrad
Schneider Deviance and Medicalization...TUP,
1992)

• i) some behaviour is defined as deviant
• ii) the behaviour is defined as a medical problem
  in e.g. a professional journal
• iii) medical and non-medical interest groups make
  claims
• iv) claims are legitimized
• v) medical deviance designation is
  institutionalized

30
Gambling (I)(White An Introduction to the
Sociology of Health and Illness, Sage, 2002)

• i) in the 19th century America gambling at odds
  with Puritan culture of capitalist work ethic a
  moral deviance
• ii) 1943 Bergler discusses the neurotic gambler
  in a scientific paper the claim of a medical
  discovery
• iii) 1957 Bergler publishes first book on the
  topic GA founded claims making and different
  interests

31
Gambling (II)(White An Introduction to the
Sociology of Health and Illness, Sage, 2002)

• iv) 1978 first hospital-based therapy team
  legitimacy i.e. securing the medical definition
  of a social problem in need of medical treatment
• v) 1980 DSM III pathological gambling
  institutionalization of a medical definition
• Conclusion a medical condition is created by
  defining action as a disease in need of
  professional medical help

32
Medicalized reproduction

• pregnancy and childbirth are biological,
  technological, social and cultural processes
• there are big socio-cultural differences in how
  reproduction is understood
• according to the basic feminist critique,
  reproduction has become medicalized in ways that
  should be resisted natural childbirth as an
  alternative

33
Geneticization as an important contemporary form
of medicalization

• geneticization refers to the way in which
  diseases, conditions and behaviours may come to
  be regarded as being determined, wholly or in
  part, by genetic factors increasingly many of
  societys problems are being explained by genetic
  influences, upon which solutions may be based -
  Gabe et al. Key Concepts in Medical Sociology,
  Sage 2004

34
Marxist critique of geneticization

• status and/or economic interests of medical
  geneticists and drug companies lead to
  exaggeration of assumed medical break-throughs
  and their relevance to curing diseases
• individualistic bias geneticization turns
  attention from effective social causes of illness
  and disease to genetic fates of individuals

35
Some criticism of marxism (I)

• theoretically blunt to conceptualize people only
  as victims of the capitalist medical system
  (patient-worker exploited by doctor-capitalist)
• it is nihilistic, if capitalism is given no
  credit for increased life expectancy,
  improvements in the diet, reforms in sanitation
  and the supply of clean water, better
  contraceptive technologies, progress in medical
  treatment and drug therapies (Lupton Medicine as
  Culture, Sage 2003)

36
Some criticism of marxism (II)

• marxist calls for a health reform are
  theoretically and pragmatically contradictory, if
  people are conceptualized as passive victims of
  the capitalist medical system
• highest scientific and technological standard of
  medical care may be possible only in capitalist
  societies
• capitalism and modern natural sciences have
  developed in a close mutual relationship

37
Some criticism of marxism (III)

• the material does not determine the social,
  cultural, spiritual etc., in any strong sense,
  because no principal distinction can be drawn
  between the material and the non-material
• it is an empirical research question, how
  elements reasonably denoted material and
  non-material together produce e.g. social
  phenomena of health and illness

38
Some criticism of the medicalization thesis (I)

• the thesis describes social phenomena but does
  not explain them
• no clear consensus about the sources of
  medicalization (gendered and asymmetrical power
  relationships, rise of bureaucratic and
  technological expert systems, interests of
  professions...)
• is it always (ever?) a bad thing that a social
  phenomenon is medicalized?

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Some criticism of the medicalization thesis (II)

• ideological roots of the medicalisation critique
  the ideals of MC are characterised by the
  idea that an individuals autonomy may not be
  violated by other, more powerful individuals
  the critics think that medicalisation means the
  displacement of rational and independent human
  activity so that a group with power is
  allowed to dictate the behaviour of others
  (Lupton Foucault and, Routledge 1997)

40
Some criticism of the medicalization thesis (III)

• if autonomy, freedom, independence etc. are not
  understood ideologically but empirically, then
• i) individuals that a medicalization process
  takes a hold on can greatly vary in respect to
  autonomy, freedom and rationality of their
  conduct, and ii) medicalization process may boost
  autonomy or freedom of some individuals rather
  than suppress it (alcoholics, persons suffering
  from ADD?)

41
Social constructionism

• social constructionism rejects a sharp
  distinction between real and false diseases
• in a sense, all illnesses and diseases are
  medicalized, that is, they have been brought
  into reality by socio-historical processes
• social constructionists reject the marxist
  concept of power

42
Social constructionism with a Foucaultian edge

• i) negative and oppressive power is real enough,
  but a more central role in social life (and in
  phenomena of health and illness) is played by
  positive and productive power
• ii) it is theoretically fruitful to conceptualise
  power as a network, which is not owned by anybody
  but which can give all individuals some temporary
  chances to effect the flows of power in their
  social world

43
Foucault on making of subjects and on power

• The objective of my work has been to write
  history about the different ways how human beings
  are made into subjects in our culture. (Foucault
  1982, p. 208)
• Power becomes valid through the fact that
  not only does power heavily press us as a force
  saying no, but it penetrates things and makes
  them exist it creates pleasure and produces
  discourse power must be viewed as a
  productive network that goes through the whole
  social body (Foucault 1984, p. 61)

44
Networks of productive power

• A network of productive power can be interpreted
  as an open strategic game, the progress of which
  subordinates individuals and groups and makes
  them secondary but which creates positions for
  everyone to change the direction of the partial
  flows of power
• power relationships, instead of specific
  individuals in the network, must be the key
  subject of socio-historical analysis

45
Against the false ahistorical humanism

• the illusion of humanism according to Foucault
• human beings have through thousands of years and
  in different cultures been quite similar
  individuals always have their characteristically
  human faculties of freedom, rationality and
  autonomy, in other words, a kind of universal and
  ahistorical nuclear self
• to Foucault there is no such self but a human
  being is a historical creature through and
  through

46
Against the illusions of conventional social
theory

• it is impossible to explain social phenomena in
  the sense that some social theory would be able
  to grasp the real causes or mechanisms behind
  social phenomena (why-questions)
• Foucaultian analysis focuses on how-questions
  how have historical processes generated humans
  and the reality intertwined with them to their
  existing form?

47
Foucaultian definition of discourse (part 1)

• He Foucault identifies discourses as
  historically varying methods of defining
  knowledge and facts that is, the things that
  can be discussed at any particular moment. They
  (scientific discourses in particular) operate as
  a set of rules, and these rules and concepts
  operate as a part of programs specifying how
  things are or are not for example, what creates
  and defines insanity.

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Foucaultian definition of discourse (part 2)

• For this reason, discourses are charged with
  power. Those who are stigmatized as crazy,
  hysterical women or frigid wives fall into the
  grasp of power. This power may be exercised by
  officials at institutions or through many other
  practices, but power is created in discourses and
  places itself in the discourses of clinical
  medicine, for example. Discourses produce facts,
  and we may only exercise power through the
  creation of truth (Foucault 1980, p. 93).
  (Ramazanoglu 1993, 19).

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Prospects of emancipation

• universal and timeless truths we could do nothing
  about, but truths as a certain kind of effects
  caused by historically shaping discourses are, at
  least in principle, open to change
• it is in the nature of power to cause resistance
  to itself to emerge (power is not violence, which
  suppresses all resistance)
• negative power is not necessarily bad positive
  power is not necessarily good

50
Negative and positive power

• evaluation of functioning and consequences of the
  different (negative and positive) forms of power
  must take place case by case
• evaluation is based on our ethical and political
  values
• the network of power is an undivided whole what
  is called negative and positive power do not
  carry any distinctive signs on the basis of which
  we could distinguish the two modes of power like
  some natural observable facts in reality

51
Power/knowledge

• truths and knowledge are always products of
  discursive power relationships in some network of
  power, and knowledge is a kind of launching pad
  to operations of power
• the Foucaultian conceptualization problematizes
  naïve hindsight in understanding the historical
  development of medicine

52
The case of drapetomania

• A disease suffered by slaves in the Southern
  states of US in the 19th century
• it manifested itself as repeated escape efforts
• slave owners were puzzled, because they thought
  of themselves as benefactors
• the disease was diagnosed by medical doctors and
  they ordered a treatment removal of a slaves
  both big toes

53
Typical(?) reactions to the case of drapetomania

• there never was such a disease
• that some doctors diagnosed this disease is
  explained by their growing up in a racist society
  and possibly also by their power ambitions, which
  strayed them away from scientific principles
• did the doctors sincerely believe in the
  existence of such a bizarre disease?

54
Foucaultian comments on the case of drapetomania
(I)

• the past has left e.g. texts and documents but it
  has not left any basis to speculate on past
  peoples sincerity etc.
• what can be done is to collect as many historical
  documents as possible about drapetomania, and to
  find the discursive methods and rules, which
  ordered emergence, diagnosis, treatment and
  disappearance of drapetomania

55
Foucaultian comments on the case of drapetomania
(II)

• what is called ideological and political biases
  cannot be removed from the medicine because they
  have always centrally constituted the medicine
  and so cannot be considered biases
• there was nothing inevitable in the disappearance
  of drapetomania, but this was a result of
  contingent historical changes in certain
  discursive power networks and their interactions

56
Criticism of Foucaultian views

• the Foucaultians are blamed for nihilistic
  relativism, which rejects existence of objective
  scientific truths and reduces everything into
  political struggle over power
• idea that the Foucaultians turn everything into
  relativistic power struggle derive from
  humanistic ideas that the Foucaultians explicitly
  reject
• we are ourselves products of usually very
  enduring discursive power networks which cannot
  be much changed at anybodys will

57
Foucaultian lessons

• there is nothing inevitable in the ways the
  medical science has developed or will develop
• do not ask what is true, but ask what kind of
  discursive power networks define the rules for
  distinguishing truths from falsities
• though flesh is not a social construction but a
  biological product, all the ways in which we
  describe, conceptualize and treat flesh are
  inevitably and varyingly socially constructed