Aim and Scope:
Health and illness are, surely, simply biological descriptions of the state of our bodies. When we’re ill, we’re ill. A more refined version of this common‐sense view underlies the long‐standing biomedical model of disease, which is based on the following assumptions:
· Disease is an organic condition: non‐organic factors associated with the human mind are considered unimportant or are ignored altogether in the search for biological causes of pathological symptoms.
· Disease is a temporary organic state that can be eradicated – cured – by medical intervention. Disease is experienced by a sick individual, who then becomes the object of treatment.
· Disease is treated after the symptoms appear – the application of medicine is a reactive healing process.
· Disease is treated in a medical environment – a surgery or a hospital – away from the site where the symptoms first appeared.
This model has dominated medical practice because it has been seen to work. It is based on a technically powerful science that has made a massive contribution to key areas of health (for example, vaccination). The anatomical and neurophysiologic structures of the body have been mapped out, and the genetic mapping of the body is being undertaken through the Human Genome Project. The search for the fundamental – that is, genetic – basis of human pathology is on, whether the target is cancer, AIDS or Alzheimer’s disease. This ever closer and more sophisticated inspection of the body –or as Foucault (1977a) would say, the medical gaze – has brought considerable power and prestige to the medical profession. It has also established a large and profitable market for major pharmaceutical companies. The biomedical model also underlies the official definition of health and disease adopted by state and international authorities. National governments and international agencies such as the World Health Organisation (WHO) proclaim their long‐term health goal to be the eradication of disease. Sometimes they have been successful, as in the global elimination of smallpox. The rational application of medical science is therefore a hallmark of modernity, inasmuch as it has depended on the development over the past two centuries of a powerful, experimentally based medical analysis of the structure and function of the body and the agents that attack or weaken it. During the course of this, scientific medicine has effectively displaced folk or lay medicine. Modernity is about expertise, not tradition; about critical inspection, not folk beliefs; about control through scientific and technical regulation of the body, not customs and mistaken notions of healing.
Yet the power and status of the medical profession and the health industry in general should not deflect us from asking about the social basis of health and illness. In fact, the position of medical professionals is itself a result of the socially institutionalized power to define the experience of being ‘ill’ and decide what treatment is required. More reflective doctors will acknowledge that their definitions of health and illness are not always shared by their patients and therefore have to be promoted through education, socialization and expensive advertising. Symptoms that, according to the biomedical model, should force us to go to the doctor or take a pill are not necessarily seen as signs of illness by people themselves. Among a household of smokers, for example, the morning ‘smoker’s cough’ is unlikely to be seen as abnormal or a sign of ill‐health: indeed, it is often calmed by a good pull on the first cigarette of the day. Among many Westerners, a suntan suggests health and good looks rather than leading to wrinkled skin or skin cancer. Among the Madi of Uganda, illness is often associated with failure to deal properly with interpersonal relations, so that social or moral – rather than biomedical – repair is needed (Allen, 1992).
Thus an alternative or complementary remedy for ill‐health often takes a holistic approach to understanding the cause of illness and its remedy.
Sociologists, anthropologists and historians have described the social basis of health and illness in a wide range of studies, including ethnographies of specific communities. They have explored issues of health care, performance of ‘the sick role’, the construction of mental illness as a disease, the wider creation of medical belief systems and the relationship between these and the exercise of power and social control.
The sociology of health and illness is concerned with the social origins of and influences on disease, rather than with exploring its organic manifestation in individual bodies. The sociology ofmedicine is concerned with exploring the social, historical and cultural reasons for the rise to dominance of medicine – especially the biomedical model – in the definition and treatment of illness. These fields are closely related, since the way in which professional (or orthodox) medicine defines and manages illness reflects wider social dynamics that shape the perception and experience of disease.
The relationship between individuals and the society or structure in which they live is specific and distinct. A helpful example of the way on which structure (society) influences the actions and experiences of individuals is provided by Giddens. He uses the analogy of language to illustrate the relationship that individual have with the wider social structure. None of us has invented the language that we use but without it the social activity would be impossible because it is our shared meanings that sustain society. However, as Giddens (1994) also points out, each of us is capable of using that language in a creative, distinct and individual way, and yet no one person creates language. In the same way human behavior is not determined in a mechanical way by the structure we call society. The relationship and interplay between society and individual is explained in terms of Structure and agency. The latter is a concept used to refer to a cluster of ideas about the potential for individuals to determine their lives, to change their environment and ultimately influence the wider structure. The concept of agency therefore, allows us to appreciate the way in which we are shaped by society and in turn shape society.
If the subject‐matter of sociology is human society and behavior is explained primarily in terms of ‘structure’, than this logically denotes specific factors in the explanatory framework of the discipline. Sociological explanations of what determines our state of health will necessarily differ from, for example, biological explanations. Clearly disease is a biological and physical entity experienced through the medium of the body. The cause of the disease, while biological, can also be considered in terms of social and structural factors. The immediate cause of disease may be infection but the factors that lead to this may be many and varied. This we may call as the social determinates of health. The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities ‐ the unfair and avoidable differences in health status seen within and between countries. Some of these social and environmental factors such as age, social class, ethnicity, race and gender fall within the scope of health sociology.
Class refers to a complex stratification of society based on access to and control of power, status and economic resources. It is a complex and dynamic power relationship between people. Class societies are also distinct from other societies that are also stratified. For example in feudal society distinction between people was rigid, immobile and seen to be religiously ordained. The reason why someone was a lord or a peasant was because God willed it that way and there was no way to change it. But in contemporary societies one can be more socially mobile between classes. This is because, in many ways one achieves one’s own class position and it is not fixed by his birth.
There is a great deal of difference between people’s life expectancy depending on the class to which they belong. If someone is from manual or working class background, generally speaking, likely die younger, age faster and encounter more long‐term limiting illnesses than someone from a non‐ manual or middle‐ class, background. This lamentable state of affairs has been apparent in much of the research looking at class and health for some time now. Going back to the mid‐1800s, Marx’scollaborator Engels wrote about the poor health of the working class in Manchester. He claimed that the levels of disease, illness and death were a form of ‘social murder’ committed by bourgeoisie. More recently, landmark reports such as the Black Report published in 1980 and the Acheson Report published in 1998 both strongly indicated that which class you are in affects your health. However there are two perspectives such as Psycho-social perspective and Neo-material perspectivethat attempt to explain the existence of class and health inequalities. Both ofthe approaches are provided by Lynch et al. (2000).
Psycho‐social perspective refers to explanation of class and health inequality that emphasize the negative emotional experiences of living in an unequal society, particularly feeling of stress and powerlessness. Wilkinson’s (1996) work in the 1980s and 1990s demonstrated that in influent societies it is relative, not average, income that affects health. Wilkinson argues that the greater the inequality in a given society, the less social cohesion it has and therefore, the more insecurity and isolation experienced by the most disadvantaged groups in that society. This insecurity and isolation result in greater levels of chronic stress. In turn, this chronic stress moves down biological pathways (particularly the nervous system) in the human body causing all sorts of harm.
Neo‐material perspectives refer to explanations of class and health inequality that emphasis unequal distribution of resources such as housing, income and access to education.
Thus, there are consistent and persistent differences in class and health in contemporary society. Such differences are part of the array of inequalities to do with wealth, income and other recourses. Perhaps it is in health that the social division of class is most evidently visible, with the bodies people affected and changed by their location in society. As discussed earlier the bodies of working‐class people are more likely to age quicker, be more susceptible to illness and be much more likely to encounter limiting long‐term conditions than those located higher in society.
Race refers to biological differences between people based on skin colour and other physical features, though the actual differences between them genetically are extremely small. Ethnicity refers to the cultural heritage and identity of a group of people where a common cultural heritage is socially learned and constructed. Race is supposed to be based on biological or genetic traits where ethnicity is purely social phenomena. Racism refers to the supposed racial superiority of one group over another.
There has been much research on ethnicity and health over the years. What much of the research indicates is that there is a burden of ill‐health among ethnic minority groups in the UK. Many people from ethnic minority groups report poor health and long‐term limiting illness. This is even more notable as ethnic minority groups tend to have a younger age profile than the white majority population. Researchers in the past often favored explanations that drew attention to either genetic or cultural reasons for ill health. The implication was that there was something wrong with the biology of ethnic groups, which predisposed them to certain types of ill‐health or that the culture of the ethnic group was to blame. An indicative example of this older approach can be noted in research on ‘South Asians’ and coronary heart disease (CHD) (Nazroo1998). Work by Gupta et.al. (1995) inferred that it was something to do with either the genetic make‐up of ‘South Asians’ that predisposed them to CHD, something in cultural practices such as cooking with ghee, nor exercising or not making the best use of medical services. In the past few years, however the work of other researchers, such as Ahmad (2000), Nazroo (2006) and Smaje(1996), have put forward a more challenging and sophisticated explanation of the complex way in which ethnicity , society and health interact. As Higginbottom (2006:585) usefully summarizes, variations in ethnicity and health and ill‐health, ‘arise from the coalescence of complex factors such as migration, cultural adaptation, racism, reception by host community, socio‐economic influences, and prevailing societal ideologies’. Reviewing a range of research and reports, Chahal(2004) concluded that medical and health care services can be problematic for Black and ethnic minority people, with negative experiences of medical and health services being a common problem. This is particularly evident with mental health services. Black people are over represented in mental illness statistics, more likely to be placed in secure wards and to receive different if not poorer –treatment and care than Whites. Thus, class and socio‐economic differences affect the health of ethnic minority groups. Even within the same ethnic minority group there are differences in health, with those from the non‐manual occupation class having better health than those in manual occupation classes. Moreover psycho‐social effects of racism can have a strong impact on the health of ethnic minority groups.
Gender refers to social, cultural and psychological differences between men and women. It is the socially constructed differences in roles and responsibilities assigned to men and women in a given culture or location and the social structure that supports them. Gender roles and expectations are learnt. They can change over time and they vary within and between cultures.
The study of gender and health has recently undergone a period of change and transition. How being a woman or a man affects one’s health are currently being developed and developed in a new and interesting way. However we cannot ignore the traditional perspective of discussing gender and health which could be easily summarized as’ men die and women suffer’, means when it comes to health differences between men and women, men experience higher levels of early mortality, while women live longer but experience higher levels of morbidity during their lives. The reasons for these differences were often explained by reference to paid and domestic work roles as well as the wider and often stereotypical, social roles, which men and women held.
Though traditional perspectives on gender and health produced a great deal of vital and interesting research, recently certain sociologist, such as Kandracket al. (1991), Annandale and Hunt (2000) and Macintyre et al. (1999), have focused on a new understanding of health and gender. Much of this contemporary thinking of relation between health and gender has been prompted by two influences.
· Firstly, the society is becoming more complex regarding gender relations. Many of the old assumption about gender‐ for instance the man as breadwinner, going out to earn the family wage and the woman staying at home tending to domestic chores‐ simply no longer fit today’s society. There have been many other transformations, shifts and movements in how women and men relate to the home, to work and to each other. In the midst of all this change women’s and men’s health is affected in new ways.
· Secondly, there is growing questioning of the theories used to conceptualize gender. So adequate understanding of how issues relating to gender affect both sexes is needed. So emphasis is now lies on understanding the lived experiences of both women and men and acknowledging that differences exist within each sex.
Annandale and Hunt (2000) have recently pointed out that research in the study of gender and health is at a crossroads with ‘traditional’ approaches giving way to ‘new’ approaches. The traditional approaches as mentioned earlier view that men and women are located in very distinct and different social roles (man in full‐time paid work and women in the home). Theses social roles required them to act in certain ways, which were, generally speaking, good for men but bad for women. The new approach hold that social roles may be ‘masculine’ or ‘feminine’ in orientation (such as running a business or looking after children) but a man may carry out a feminine role (looking after children), while a woman may occupy a masculine role as ( running a business). The new approaches also focus on how men and women experience those roles and how those experiences affect their health (Annandale and Hunt 2000). The more ‘feminine’ a role, the lower status it tends to have and this can lead to poor health. Performing feminine roles also carries much more pressure than performing male roles.
Annandale and Hunt (2000: 27‐9) usefully summarize the differences between ‘traditional’ and ‘new’ approaches to gender and health:
· ‘Traditional’ forms of research had the tacit assumption that what was good for men was bad for women when it comes to health. ‘New’ research follows a more nuanced and subtle approach, and understands that similar circumstances may have similar or different consequences for the health of men and women.
· ‘New’ approaches are aware of the differences within men and within women. In traditional research men in particular, were treated as an undifferentiated group, where all men had similar health experiences.
· In traditional research positivist, quantitative, statistical methods were predominant. In new research the role of qualitative method is highlighted in trying to obtain an understanding of how the experiences of men and women shape their health.
One long‐held view is that women have higher morbidity rate than men. There have been a number of reasons behind this, for example:
· Women do experience more ill‐health than men because of the demands of their social roles.
· Women are more disposed to seek help than men.
· Women are more in‐tune with their bodies.
· Surgeries are not male friendly and put men off seeking help.
· It is easier for women to adopt the seek role.
· Women’s more attachment to their relation result different kind of mental diseases including stress.
Another long‐standing perception, when looking gender and health, is that women have some form of biological advantage in terms of life expectancy. In the UK, for instance a woman born in 2004 can expect to live until she is 81.1 years old, while a male born in the same year can expect to reach the age of 76.7 years (ONS 2006). Such statistics strongly suggest that women do enjoy some form of biological advantage over men. However the sizable life expectancy advantage that women experience in the UK is very much a western phenomenon. Figure depicts how overall women do have longer lives than men in most countries but this is extremely variable. On one hand, in some countries, such as Malawi, the life expectancy for both men and women is very low, while in Algeria there is a negligible difference in life expectancy for women and men. The reasons for this are multiple and diverse. For example it depends on levels of health care a country can offer, where child birth is safer, the levels of poverty and endemic illness, such as in Malawi, which faces widespread poverty and has many people infected with HIV/AIDS.
Mental health as an important aspect of heath system comes directly under the scope of health sociology where it has an important role to play in trying to understand the full intricacies of mental illness, especially when it comes to the way in which society influences and frames both how we see mental health and illness and how society creates situations that can negatively impact on individual’s mental health.
There are complexities and uncertainties that surrounded the whole processes of diagnosis and identifying mental illness. Unlike physical illness, there is often no clear‐cut objective sign that someone is experiencing a mental illness. McPherson and Armstrong (2006:50) this concern well, when they say:
What is pneumonia or appendicitis or cancer can be agreed internationally with reference to the presence or absence of certain clearly defined physical characteristics. In psychiatry, however, there is no such external biological referent to act as an anchor for diagnosis. Essentially, psychiatry classifies on the basis of a patient’s patterns of symptoms which might vary according to how they are elicited and interpreted.
Because then it cannot always clearly identified what mental illness is, this makes the search for a cause all the harder. Broadly speaking, explanations for mental illness fall into one of two camps: biological explanations and social explanations. These look in very different directions and see quite different reasons for the existence of mental illness.
· Biological explanations focus on faulty genes or imbalance in the chemistry of the brain. There is, for instance an association between low levels of serotonin and depression. This way of thinking, of looking for biological cause, in increasingly reinforced by the proliferation of pharmaceutical interventions such as SSRIs (selective serotonin reuptake inhibitors) for treating depression which suggest that if an illness can be treated by chemicals, than it must have a biological, organic basis.
Social explanations fall into two general categories: Social causation and Socialconstructionist.
· Social causation perspective refers to how the various inequalities in society (mainly to do with ethnicity, gender and class) produce toxic levels of stress for some people. As a result of this stress, people may be ‘tripped’ into mental illness, whether it is a woman expected to bring up children on her own and keep down a job; or the experience someone from an ethnic minority group has of being racially abused by a neighbor; or the constant soul destroying grind of poverty and not being able to lead the life of that others enjoy.
· Social constructionist explains mental illness is something that does not exist as a ‘fact’ or something that is ‘real’ and has absolutely no organic basis. This sociological view is influenced by the work of Foucault, who has argued that there is no single incontestable truth that can be discovered and agreed on by everyone. Rather, society is constructed by the idea and conceptualizations of both individual people and also, more importantly, certain powerful groups. Some groups, such as psychiatrists, are able to construct a discourse that privileges a certain view point of others, which allow them to effectively rule out and rule in ways of conceptualizing, for example what constitutes mental illness. Constructing such discourses allows such groups to become dominant in society and allows them to regulate and control the activities of others.
Thus, both biological explanations and social explanations explain about mental illness. But these two are not sufficient to address the complexity of mental health and illness. Rather there is a complex interweaving of both society and biology, where both have to be understood as often working together in complex and dynamic ways. As captured by Rose (2005) in his discussion of causes of mental illness and how biology and society interact. He points out that just because a change in the chemistry of the brain takes place does not mean that the chemical change caused the illness. To illustrate this point he gives a beautiful example: if someone has a headache, he takes an aspirin. If we
were then to check the chemicals in the person’s brain in order to discover the chemical basis of a headache, we would find aspirin. Thus, according to the biological explanation, we would claim that aspirin causes headache, because people who do not have headaches do not have the chemical aspirin present in their brains. Now, obviously, this not to be the case. So, Rose concluded that chemical changes do occur, but that could equally be the result of other (in this case social) factors.
Pilgrim and Rogers (1994) acknowledges and develops the social and cultural factors responsible for mental health in their studies. According to them the misery and sufferings of the world is related to the complexities of human life: that humans are simultaneously organic biological and social beings. This critical realist perspective fully acknowledges the strong and influential role of culture, but does not say that it is all down to society. It also accepts the importance of medical information and research, but crucially, questions how diagnoses are framed by the social influences on the medical professions. Finally, a critical realist perspective accepts that biological processes are at work but, like Rose (2005) attempts to place those processes in a wider context where social factors may be the cause of biological changes.
Stigma refers to an attitude that ‘discredits’ or prevents someone’s full acceptance in aparticular situation. Social stigmas increase the stress of those with mental illness and exacerbate feeling of social exclusion and social distance.
Goffman is one of the best known sociologists to have studied and theorized how certain groups of people attract stigma. His humanistic and sympathetic work focuses on why certain attributes of an individual or group deny them full acceptance in given situations and lead them either to be excluded or to be left with a feeling of not ‘fitting in’. He classifies stigma into three broad groups:
· Physical stigma ‐ mainly to do with aspects visible ‘on the surface’ of people, for example facial scarring, a physical impairment or an amputation.
· Personal/character stigma ‐ mainly to do with aspects ‘below the surface’, for example drug use, sexuality or mental health.
· Social stigma ‐ belonging to a particular group or ethnic minority. (Goffman, 1968)
The ‘counting the cost’ survey by Baker and Macpherson (2000) for MIND highlighted the extent of stigmatizing images and the effects they had on people with mental illness. For many respondents to the survey the social stigma was harder to deal with than the symptoms of their particular condition.
There are a number of explanations for why people from Black and other ethnic backgrounds appear to have higher rates of mental illness and a different, often coercive, relationship with services. These explanations include:
· racist and prejudiced attitude on the part of service providers and agencies of the state, such as the police;
· lack of cultural sensitivity
· more frequent exposure to stressors in the form of, for example, unemployment; adjusting to a new society if recently arrived;
· racism generally.
However, Pilgrim and Rogers (1993) pointed out another related concept regarding the relationship of ethnicity and health. They draw on Foucault’s concept of seeing madness as a part of the ‘other’, that is the groups of people who are regarded as being outside the norm of society and as constituting a threat to the order of society.
Every review of literature concerning sociology and mental health reaches the same conclusion when discussing gender – that women always display higher rates of certain mental illness than man (Foster 1995; Bebbington (1996).
In substantial review of literature relating to women and depression Bebbington (1996) and Nazoo et al. (1998) demonstrated the following points:
· Women did report more depressive episodes – whether distant, mild or exaggerated episodes. Whereas there is little evidence for men masking their depression by turning to alcohol or substance abuse.
· The chance of depression is higher in case of woman because of her role identity. For example: a woman feels a particularly close attachment to and sense of responsibility for children and because of her role identity, then the chance of depression is much greater if there is child related problem, such as difficulties at school or drug misuse.
One of the best known pieces of sociological research on women and mental health was carried out by Brown and Harris (1978). Key component of the model are:
Current vulnerability factors – these factors relate to events that have happened in a woman’s past and indicates whether or not she may be more susceptible to depression. There are four vulnerable factors:
· losing a mother before the age of 11;
· presence at home of three or more children under the age of 15years;
· absence of any confiding relationship, particularly with the husband;
· lack of full or part‐time job.
Provoking agents – there are various events that could occur in a woman’s life, which could then trigger a depressive episode. The events mainly relate to loss and disappointment, e.g. death, losing a job or discovering a partner’s unfaithfulness.
Symptom – formation factors‐ women over 50 years of age and women with low self‐esteem were at greatest risk of developing depression.
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