Guide to the vibrant and



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buffers, such as coping resources and social support

networks. This literature has shown clearly

that social integration is positively linked with

mental and physical health and with lower mortality.

The most powerful form of support is intimate

relationships, and emotional support can

provide protection against adverse life events.

Most recently this has been associated at the societal

or group level with theories of social capital.

The concept of social or holistic health is more

than simply the recognition that social factors

such as poverty or behaviors have to be included

in any model of the causes of ill-health. It locates

biological processes within their social context,

and considers the person as a whole rather

than a series of bodily systems. It is organic rather

than mechanistic and reductionist. Human beings

are living networks formed by cognitive processes

and purposive intentions, depending on

the meanings ascribed to bodily phenomena, not

simply machines.

The development of the social model has been

accompanied, among the public, by a growing

enthusiasm for alternative and complementary

therapies, which tend to be more holistic. These

have also been incorporated to some extent into

mainstream medicine. In the social model, health

is a positive state of wholeness and well-being,

associated with, but not entirely explained by,

the absence of disease or mental or physical impairment.

The concepts of health and ill-health

are not simply opposites.

In 1948 the World Health Organization defined

health as “a state of complete physical, mental

and social wellbeing, and not merely the absence

of disease or infirmity,” and this is generally held

to epitomize the social definition of health. This

definition has been criticized as difficult to measure

and impossible to achieve, and as promoting

the medicalization of all aspects of daily life. However,

it draws attention to the holistic and socially

conscious definition of health which is most

favored in contemporary western societies and

medical systems.

Whether health is considered negatively, in

terms of disease, or positively, in terms of holistic

health, it is necessary to distinguish between objective

and subjective health. In English-speaking

countries it is usual to give different meanings to

the words disease, illness, and sickness. Disease is

the medically defined pathology. Illness is the

subjective experience of ill-health. Sickness is the

social role of those defined as diseased or ill.

There are problems about this usage, since not

every language has equivalent words, but it has

value in emphasizing that these concepts are not

the same.

health health

262

People may be ill, that is, feel themselves to



have something wrong with them, without

(known) disease. In the doctor’s office, the person

with an illness may be transformed into a patient

with a diagnosis, that is, a disease. It is possible to

be subjectively ill or to be medically diagnosed as

having a disease without adopting the role of the

sick person – that is, without assuming or seeking

permission to give up normal roles. People may

have a disease, or be injured or functionally incapacitated,

without being ill or claiming to be sick. It

is very common, in surveys of self-defined health,

to find people with severe disability claiming that

their health is “excellent.” Moreover, it has been

noted that modern medicine produces many liminal

states which are neither ill nor well – potentially

ill, but at present well, in remission but not

cured, at known risk of disease which has not yet

developed. A commonly cited epigram is “disease

(and trauma) is what doctors treat, illness, is what

patients experience.” Though attractive, this is

somewhat facile: doctors do treat illness, even in

the absence of anything that can be diagnosed as

disease, and patients do subjectively perceive and

self-define disease.

The distinction between disease, illness and

sickness is paralleled by the usage, in the field of

disability studies, of the terms impairment, disability,

and handicap, as promulgated by the

World Health Organization in their “International

Classifications” of disabling conditions.

In the early days of medical sociology, the

American sociologist David Mechanic, in his Medical

Sociology (1968), defined illness behavior as the

way in which “symptoms are differentially perceived,

evaluated and acted upon (or not acted

upon) by different kinds of people and in different

social situations.” The concept included, as well as

what Irving Zola called the pathway from person

to patient, the whole process of seeking help, including

the “lay referral system.” Classic work,

particularly in the United States, mapped out the

way in which groups in society might differ in

their responses. The concept became extended to

include their perceptions of the illness and its

treatment, and their heath-promoting or healthharming

lifestyles. Many models, largely variants

of the “health belief model” described by Irwin

Rosenstock (Health Education Monographs, 1974),

were used, especially in health psychology, to formalize

the processes by which perceived illness is

translated into sickness, and offer explanations of

actions taken, or not taken, to promote health.

Certain disease labels carry with them public

stereotypes. More generally, in early medical

sociology the work of Talcott Parsons, defining

illness as a form of deviance which disrupted the

social system by interfering with normal role performance,

gave rise (particularly in the United

States) to a body of theory analyzing illness as

deviance. Labeling theory was applied to the secondary

deviation resulting from the identification

as being ill, especially for particular disease labels

such as epilepsy. Thomas J. Scheff, for instance, in

Being Mentally Ill (1966), claimed that labeling was

the single most important cause of the manifestations

of mental illness. The work of Erving

Goffman on Stigma (1964) was also very influential.

These concepts are still important in disability

and impairment and are relevant in specific

conditions such as HIV/AIDS.

The psychological models of health beliefs and

behavior have, in more recent decades, been criticized

as abstracted from social settings, and the

term illness behavior has become somewhat outmoded.

Studies of the perception and experience

of illness, based on phenomenology and the

methods of qualitative research, are seen as moving

away from the medical model, and turning to the

patient’s perspective.

The influence of social constructionism has

become strong in the sociology of health, especially

in many countries of Europe. It is argued

that medical knowledge is produced by and reflects

the society in which it is found. What counts

as disease or abnormality is not given in the same

sense as a biological fact is given, but depends on

cultural norms and shared rules of interpretation.

It is, as the Polish medical philosopher Ludwik

Fleck (1896–1961) suggested, a product of the

“thought style” of a particular community of scientists

and practitioners. In the version of constructionism

most favored in the sociology of

health, it is not suggested that diseases and pathogens

are not “real,” but that health is, like other

human experiences, at the same time a socially

constructed category. Much of the understanding

of how people act in illness began to come from

studies of groups suffering from particular

chronic conditions, including especially diabetes,

asthma, hypertension, heart disease, and epilepsy.

Self-regulation and control, and adjustment to

illness within a family and social context, are

prominent themes, as is illness as biographical

disruption, that is, the place of ill-health in the

lifecourse. Interest has increased in the analysis

of illness narratives, in which, as Arthur Frank

notably described in The Wounded Storyteller

(1995), individuals make sense of their experience

and create new identities.

health health

263

The search for meaning, or the answer to what



the French social anthropologists Claudine Herzlich

and Janine Pierret in Illness and Self in Society

(1987) called the “Why me? Why now?” question,

became a focus of research. Associated themes

are moral discourses of health, lay explanations

of disease, and particularly the question of selfresponsibility.

An earlier, and more specifically

psychological, model of attitudes to health as

either “internal” (health as the outcome of individual

behavior) or “external” (health as the consequence

of outside influences or simply chance)

has, largely, been abandoned. Contemporary discussion

still very much emphasizes the question

of agency and structure, however: the debate

about the extent to which people can, or feel

themselves able to, exercise individuality and

free will or are subject to various kinds of constraint.

Max Weber had provided a theoretical

background for these discussions, distinguishing

the two concepts of life conduct and life chances.

The interplay of these is a dominant theme because

of its practical and political importance

in the fields of health promotion and health

inequalities.

Relevant to this issue is the popular theme of

the commodification of health. This emphasizes

the range of dietary, leisure, slimming, and body

maintenance and decoration products which

modern commerce and culture provide, and the

emphasis on the young and fit body as a fashionable

ideal.

Theorizing health as consumption owes much



to Pierre Bourdieu, who extended analysis to the

explanation of class and group differences in

health behavior. Individual practices are connected

to culture and structure, and ultimately

to power, through the concept of habitus.

The consultation, as a basic unit of the interaction

between health professional and patient,

is a topic of particular interest in the sociology

of health. A distinction has been made between

“doctor-centered” consultations, traditionally

paternalistic and controlled by the doctor, and

“patient-centered” ones, with greater patient involvement

and a more mutual relationship. These,

and other suggested models, such as the consumerist

relationship which may be applicable in

particular circumstances, can be appropriate to

different stages and types of illness. Different

patient characteristics are also shown to be associated

with their willingness to assume a

participative role.

Within the earlier and more medical model,

there had been many studies of compliance, or

whether the patient accepts the doctor’s instructions

or takes medication as prescribed. This approach,

it was suggested, ignored the lay

meanings of medications, and their place in the

individual life, and the term adherence began to

be preferred, implying a more active, collaborative

activity. Non-compliance was demonstrated to be,

often, a rational response to experience. Concordance

is an alternative term especially popular in

primary care, suggesting a course of action agreed

upon in negotiation between patient and doctor.

Doctors’ communication skills are an important

topic in teaching and in research, as are decisionmaking

principles and practice, and the characteristics

of health care systems which may affect

interaction and the outcome of consultations.

The role of patients in decisionmaking about

treatment is an active theme in contemporary

western health systems, since the right of patients

to be involved in making informed choices is an

increasingly promulgated value.

At a more theoretical level, the relationship of

health to social systems has always been one of

sociology’s major interests. Most of the significant

differences in health between countries and

groups within countries are not biologically inevitable,

but bound up with the particular society,

its place and time, its politics, administration, and

health services. At the same time, the relationship

is reciprocal: the health of a population has economic

consequences. Health is part of a society’s

capital. Two of the most influential founding theorists

on the relationship of health and society

were E´mile Durkheim and Parsons, offering “functional”

models of society. Durkheim emphasized

the importance of societal structures, and norms

and processes which were outside the individual

but integrated them into the structure. In Suicide

(1897 [trans. 1951]) he used the example of rates of

suicide, developing a three-fold typology of egoistic,

where the individual was detached from society;

anomic, due to a state of normlessness; and

altruistic, a purposive choice. The prevalence of

this very individual act of suicide was shown to

be determined by ties to society. The concept of

anomie, in particular, proved of lasting importance

in theories about health and society.

The American sociologist Parsons, influenced by

Durkheim and by Weber, as well as by early psychoanalytic

theory, was concerned to explain

value consensus, social order, and stability. In

the major work The Social System (1951), using the

medical profession as a model, he analyzed the

needs of the system, expressed in the duties and

reciprocal entitlements of both doctor and

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264

patient. For the doctor, the pattern variables of



universalism, performance, or achievement,

rather than ascription, specificity, and affective

neutrality, were appropriate. The rights, obligations,

and privileges of the sick role described

the norms of being a patient. This ideal-type contract

was what would, theoretically, identify medicine

as functional in maintaining equilibrium in

society and maintaining social order.

However, structural functionalism lost influence

as a theoretical position in the 1960s and

1970s. The emphasis on consensus seemed to favor

the status quo and the domination of the powerful,

and the approach was found inadequate in the

explanation of change. Social conflict theory, with

its roots in Karl Marx, suggested that society was

not held together by shared norms and values, but

by those imposed by economically powerful

groups. Weber added that social differences are

based not only on economic factors, but also on

status and other forms of influence. Conflict

theory turned attention, especially, to the sources

of ill-health in the economic environment.

In the later decades of the twentieth century,

the power and pre-eminence of medicine as an

institution, combined with some disillusion

about the actual effects of increasingly hightech

medical science, led to an emphasis on a

degree of conflict between the interests of

patient and of doctor, and on medicine as an

instrument of social control in society. The medicalization

of society became a popular topic of

medical sociology.

A separate strand of theory relates to the relationship

of economic development to health. This

turns attention from the possibly oppressive

effects of the system of medicine to its undoubted

positive successes, together with economic development,

in prolonging life. Obviously, in the long

term, the health of populations increases with

economic development: even in the already developed

nations, life expectancy at birth usually

still increases from one generation to the next. At

present, two or three years are added with each

decade that passes. The causes include not only

improving material standards of living, but also

changing disease patterns (especially the relative

disappearance of infectious disease), advances of

public health and hygiene, and the non-material

advances in, for instance, education associated

with economic progress. How much is due to the

advances of medical science or improvements in

health care is disputed. Once a certain state of

development has been reached, the proportion of

Gross National Product spent on medical care, or

the way in which care is organized, does not seem

to have any clear association with differences in

the longevity of populations.

Expectation of life has been markedly influenced

by the steep fall in infant mortality in the

developed world, rather than by much extension

of life in old age: this fall has now reached a stage

where little more is possible. The possibility of

treating ever more diseases does, however, alter

the health profile of populations. The shift from

acute (infectious, commonly fatal) disease to

chronic (long-term, to be controlled rather than

cured) means that longer life may mean an increase

in the actual experience of ill-health. This

has an effect on the burden placed on health

services.

A corollary of the political and economic view of

the relationship of health to social structure is

that capitalism necessarily creates inequalities between

sections of populations. The minimization

or correction of these inequalities is a major concern

of western health systems, and inequality in

health has been one of the most active areas of

research and discussion in medical sociology for

some three or four decades.

Obviously, simple equality in health is impossible

to achieve in any society: differences associated

with genetic inheritance, the geographic

environment, or pure chance (and of course age)

are part of the human condition. The patterning

of inequality shows that the issue is not related

only to the extent of economic deprivation, with

deficiencies in such things as food, living environments,

or medical care. In effect, the term “inequality

in health has come to mean a special

sort of difference – that difference between individuals

or groups which is: socially determined,

rather than due to biological factors; felt to be

unjust and inequitable, and not the individual’s

own responsibility; held not to be inevitable,

that is, it could, with current technologies and

knowledge, be alleviated.

Thus the concept of equality in western societies

is highly constructed and dependent on the

progress of science and on ethical positions. It is

more than equity of health-service provision,

though “equality of provision for equal need” is

a common way in which policy tries to find a

services-relevant description.

The measures of equality most often used are

rates of death or life expectancy. Since life expectancy

at, say, age 65 and at birth may be differently

patterned, years of healthy life, or potential years

of life lost (PYLL) before the age of 70, are measures

which can be used. Inequalities may also be

health health

265

measured in absolute terms (simple differences



between two groups) or in relative terms (for instance,

the ratio of death rates in the lowest social

group to those in the highest). The latter may

appear to exaggerate inequality if rates are low.

Approaches to the problem of inequality in

health vary widely throughout the world. In lowincome

countries, the causes may clearly be material

and the urgent questions may be political

and economic ones, including the provision of

health care. A strong emphasis on equality of

access is also found among some of the wealthiest

nations, such as the United States, with largely

privatized health services. Countries with large

ethnic or indigenous groups may also be particularly

concerned with the health care of different

races.


In the United Kingdom there has been a tradition

of public concern about unequal health ever

since the mid nineteenth century, when pioneers

such as Edwin Chadwick (1800–90) described the

living conditions of the poor and noted their low

expectation of life. Concern about inequality

remained in the early years of the twentieth century,

and was offered as one major justification

for the setting up of the National Health Service in

1948, following the Beveridge Report of l942. The

rediscovery of inequality was marked by the

Report of the United Kingdom Department of

Health (known as the Black Report) in 1980, and

in the following decades many other countries,

especially those of western Europe, took up the

issue, and the theme was one of those around

which the World Health Organization has based

its strategies.

The field has been primarily occupied with

understanding why differences linked with socioeconomic

status arise, persist, and even grow

greater. In Europe, it has been usual to rely on

occupation-based measures of social class to demonstrate

this. In the United Kingdom this classification

has been used, sometimes collapsed into

the two classes of manual and non-manual, for

almost a century, to measure differences by class

in mortality rates. Increasingly, however, the classification

scheme is seen to have problematic features

in modern society, and others are being

developed for the purpose of health statistics.

The experience of illness health also varies by

social class, though not as strongly or as regularly

as mortality. Other dimensions of inequality in

health include ethnicity and region. Certain

regions within countries show consistent health

disadvantages over others, associated with, but

in addition to, their economic or social class

composition. Everywhere, minority or migrant

ethnic groups tend to show higher rates of many




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